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Copyright N°_Z£/0: 

COPYRIGHT DEPOSIT. 



Copyright, 1916 and 1917, by Richard G. Badger 
All Rights Reserved 






V* 



OCT 27i9!7 



Made in the United States of America 
The Gorham Press, Boston, U. S. A. 



GI.A476791 
*>Vtr ( , 



TO DR. GEORGE M. KOBER, DEAN OF THE 
GEORGETOWN MEDICAL SCHOOL, THIS LITTLE 
BOOK IS DEDICATED, AS A MODEST TOKEN OF 
APPRECIATION OF HIS UNSELFISH DEVOTION TO 
OUR SCHOOL AND HOSPITAL 



PREFACE TO FIRST EDITION 

There should always be some valid reason for writing 
a new book, especially a medical book. My reason for 
writing, or perhaps to express it more accurately, for 
compiling this work, is, that the information that it 
contains is scattered quite broadly through a wide and 
extensive medical literature, that may not be readily 
accessible to all, and which has never, so far as I know, 
been collected together in book form. 

Inasmuch as every progressive physician and sur- 
geon at the present day is making more or less frequent 
use of the different functional tests, to determine the 
efficiency of vital organs, it occurred to me that to 
collect them all in one volume, together with the neces- 
sary data whereby they might be intelligibly inter- 
preted, might prove to be useful, particularly to the 
busy practitioner. 

The following work, which is an effort to carry out 
that idea, includes only the tests for so called vital 
functions, namely those applied to the liver, kidneys, 
heart, pancreas, and ductless glands. To go beyond 
this and take up the functional tests of all the organs, 
such as the eye, ear, nervous system, etc., would be to 
exceed the legitimate field of true function testing and 
to encroach upon the well-trodden fields of general 
semiology and diagnosis. 

I hope the book may prove to be useful and con- 
venient to all who are interested in this fascinating and 
ever-developing field of clinical pathology. 

3 



4 Preface to First Edition 

It is a matter of which American physicians may 
well be proud that the most substantial and brilliant 
progress in the development of tests of organic func- 
tion, particularly in reference to the kidneys and liver, 
has been brought about by the assiduous efforts of some 
of their own fellow countrymen. 

In the chapter on heart I have received valued assist- 
ance from my friend and colleague, Dr. Thos. S. Lee. 



PREFACE TO SECOND EDITION 

A new edition of the Manual of Vital Function Test- 
ing Methods has been called for within a year of the 
appearance of the first. This is exceedingly gratifying 
to the author and his colleagues who have helped him in 
the preparation of the second edition. 

The additions made are as follows : 

Dr. Thos. S. Lee, Clinical Professor of Medicine in 
Georgetown, Medical College, for whose assistance in 
the chapter on heart in the first edition I am under 
deep obligation, has added to the second edition ar- 
ticles on Sphygmobolometry, Sphygmobolography and 
Energometry. 

Dr. Lester Neuman, Associate in Pathology in the 
Georgetown Medical College, has made very valuable 
additions to the second edition which will be found in 
the chapters on liver and kidney function. These addi- 
tions include a description of the Van Slyke method of 
urea determination, Provocative Sulpho-Conjugation 
as a means of testing hepatic function, Test Meal in- 
vestigations of kidney function, Ambard's coefficient 
and McLean's index of urea excretion, Creatinin and 
uric acid estimations in blood and finally a synopsis 
of Mosenthal's and Lewis' scale of renal involvement. 

The author with the aid of one of his assistants, Dr. 
Ladd, of the house staff of the Municipal Hospital, has 
added a short description of functional tests applied 
to the Vegetative Nervous System, which is appended 
to the chapter on the Ductless Glands. 

5 



6 Preface to Second Edition 

It is hoped that these additions will bring the Man- 
ual up to date and thereby justify a continuance of the 
very favorable reception which the book has received 
among those of the medical profession who are inter- 
ested in vital function testing. 



CONTENTS 

TESTS OF LIVER FUNCTION 

PAGE 

General Considerations 15 

Functional Tests to Discover Disturbances of the Glyco- 
genic Function of the Liver 16 

The Cane Sugar Test 17 

The Glucose Test 18 

The Levulose Test 18 

The Galactose Test . . ^ 20 

Conclusions Concerning the Carbohydrate or Sugar 

Tests 20 

Functional Tests to Determine Disturbances of the Urea- 
genetic Function of the Liver 22 

Urea Elimination and Nitrogen Coefficient as Criteria of 

Liver Function 24 

Quantitative Urea Estimation in Urine (Marshall's 

Method) _ 27 

Determination of Urea in Urine (Van Slyke's Method) 30 
Determination of Urea in Blood, Spinal Fluid, etc. (Van 

Slyke's Method) 32 

Total Nitrogen Estimation in Urine {KjeldahVs 

Method) 33 

Augmentation of Urinary Ammonia as an Index of Urea- 
genetic Liver Function . . 35 

Estimation of Ammonia Nitrogen in Urine (The 

Formalin Method) 36 

Experimental Provocative Ammoniuria 37 

Aminoaciduria as a Criterion of Ureagenetic Function . . 38 
Experimental Provocative Aminoaciduria .... 39 
Estimation of Residual Nitrogen in Blood Serum as an 

Index of Hepatic Function 40 

Summary of the Value of Ureagenetic Tests of Liver 

Function 40 

Functional Tests to Determine Disturbance of the Anti- 
toxic Function of the Liver 41 

Methylene Blue Test of Toxopexic Function of the Liver 

(Chauffard-Castaigne Test) 42 

Roche's modification of Methylene Blue Test ... 42 
Indicanuria, Spontaneous and Provocative as Means of 

Testing Integrity of Hepatic Fixation 43 

Tests for Urinary IncQcan 44 

7 



8 Contents 

PAGE 

sulpho-conjugation, provocative as a means of testing the 

Hepatic Function 45 

Functional Tests to Determine Disturbance of the San- 

guinopoietic Function of the Liver 51 

Estimation of Blood Coagulation Time as an Index of Liver 

Function. 52 

Wright's Method of Fixing Coagulation Time ... 53 
The Fibrinogen Test of Whipple and Horwitz ... 54 
Estimation of Fibrinolysis Time as an Index of Liver Func- 
tion (Goodpasture's Test) 54 

Estimation of Lipase in the Blood as an Index of Liver 

Function (Whipple's Test) 56 

Lowenhart's Methods of Lipase Estimation ... 56 

Ghedini's Test 57 

Application of Abderhalden's Method to Estimation of 

Sanguinopoietic Liver Function 58 

Functional Tests to Determine Disturbance of the Exocrin- 

ous or Biliary Function of the Liver 58 

Tests for Urobilinogen, Urobilin and Bilirubin in the Urine. 
Interpretation of Results with Reference to Hepatic 
Function. The Urobilinogen Test (EhrlicKs Test) . . 63 

Tests for Urobilin 65 

Tests for Bilirubin 66 

Tests to Determine the Global capacity of the Liver to 

Eliminate Foreign Substances 67 

Phenoltetrachlorphthalein Test of Liver Function 
(Rowntree, Horwitz and Bloomfield Test) .... 67 

TESTS OF KIDNEY FUNCTION 

General Considerations 75 

Urinalysis as a Criterion of Renal Function .... 81 
Estimation of Urinary Water. Experimental Polyuria 

(AlbarrarCs Method) 84 

The Water Tests (Straus-Qriinwald Method) . . . 85 

The Diuretic Tests (Pharmacological) 86 

Estimation of Sodium Chloride as an Index of Renal Func- 
tion 87 

The Sodium Chloride Test. Test of Alimentary 

Chloruria 90 

Sodium Chloride Estimation 90 

Estimation of Urinary Nitrogen as an Index of Renal Func- 
tion 91 

Diminished and Delayed Excretion of Urea .... 93 
Forced Urea Elimination. Provocative Urea Test of 

McKaskey 95 

Test Meal for Nephritic Function 95 

Estimation of Urinary Coloring Matter as an Index of 

Renal Function ... 109 

Estimation of Urinary Diastase as an Index of Renal Func- 
tion 110 



Contents 9 

PAGE 

Study of the Physical and Biological Characteristics of the Urine 

as Criteria of Kidney Function Ill 

Estimation of Freezing Point of Urine (Cryoscopy) as 

Index of Renal Function (v. KoranyVs Test) . Ill 
Electrical conductivity of the Urine as Index of Renal 

Function 114 

Estimation of Urinary Toxicity as Index of Renal Function 115 
Studies of the Blood as Criteria of Renal Function Urea 
and Incoagulable or Rest Nitrogen in the Blood as 

Indexes of Renal Function .115 

Marshall's Method for Determination of Urea in Blood 119 
Estimation of Incoagulable Nitrogen. Morris' Modifica- 
tion of Hohlweg-Meyer Method; Folin and Denis Method 124 
Ambard's Coefficient of Urea Excretion and Index of Urea 

Excretion (McLean) 129 

Creatinin and Uric Acid Estimations in Blood . . . . 137 
Estimation of Blood Coagulation Time as Index of Renal 

Function 146 

Cryoscopy of Blood as Index of Renal Function .... 146 
Studies of the Elimination of Foreign Substances, by the 

Kidney as Criteria of Renal Function 146 

Miscellaneous Chemical Substances 147 

The Potassium Iodide Test 147 

The Phloridzin Test 149 

The Hippuric Acid Test 149 

The Lactose Test 149 

Elimination of Dyes — Urinary Chromoscopy . ... 151 

The Methylene Blue Test 152 

The Indigo Carmine Test 155 

The Phenolsulphonephthalein Test of Rowntree and 

Geraghty 157 

General Summary of Renal Function Tests 170 

Selection and Practicability of Renal Function Tests . . 179 

TESTS OF PANCREATIC FUNCTION 

General Considerations 186 

Tests of Pancreatic Function Which Concern the External 

ob Digestive Activity of the Organ 188 

Proteid Digestion Tests 190 

Schmidt's Cell Nuclei Test 192 

Sahli's Glutoid Capsule Test 192 

Fat Digestion Tests 194 

Starch Digestion Tests 197 

Identification of Ferments in Excreta as Evidence of Pan- 
creatic Function 197 

Demonstration of Trypsin in Stools 198 

Demonstration of Trypsin in Stomach Contents . . 200 

Demonstration of Diastase in Feces 202 

Demonstration of Lipase in Stools 204 



10 Contents 

PAGE 

Tests for Pancreatic Function Which Concern the Internal 

or Metabolic Function of the Organ 205 

The Cammidge Reaction 206 

Loewi's Pupillary Test . . . . B> 209 

Spontaneous and Provocative Glycosuria 210 

General Conclusions Concerning Pancreatic Insufficiency 

Tests 211 

TESTS OF HEART FUNCTION 

General Considerations 212 

Reaction and Muscular Exertion as Basis for Estimating 

Cardiac Function : 215 

The Staircase Test (Selig's Test) ....... 217 

The Ergometer Test (Graupner's Test) 219 

Mendelsohn's Test 223 

Katzenstein's Test 225 

Herz's Self-Checking Test 227 

Gymnastic Resistance Test 228 

The Russian Test 229 

The Venous Pressure Test (Schott's Test) 229 

Cardiac Reflex Estimations in Determining Heart Function 231 

Sodium Chloride Elimination and Cardiac Function . . 232 
Modern Clinical and Instrumental Methods in Cardio- 
Pathology; Their Applicability to Estimation of Heart 

Function 232 

Sphygmomanometry. Work- Velocity Ratio .... 232 
Functional Tests Based on Direct Blood Pressure Deter- 
minations ... 237 

Cardiac Efficiency Factor of Tigerstedt 237 

Cardiac Strength, Cardiac Weakness Ratio .... 238 

Cardiac Overload Factor of Stone 241 

Sphygmobolometry 243 

Sphygmobolography 251 

Energometry 253 

Roentgenoscopy and Cardiac Function 257 

Sphygmocardiography and Cardiac Function .... 258 

General Conclusions as to Tests of Cardiac Function . . 260 

THE DUCTLESS GLANDS AND VEGETATIVE 
NERVOUS SYSTEM 

General Considerations 262 

The Thyroid Gland 265 

Tests of Functional Activity 265 

Hyperfunction of Thyroid Gland 266 

Hypophysis-Extract Test of Claude, Baudouin and 

Porak . . 271 

Adrenalin-Mydriasis Test of Loewi 276 

Experimental Hyperthyroidism Test 277 



Contents 11 

PAGE 

Aceto-nitril Test of Reid Hunt 279 

Metabolic Tests of Hyperthyroidism ..... 282 

Complement-Deviation Test of Hyperthyroidism . . 284 

Abderhalden Test in Hyperthyroidism ..... 287 

Hypofunction of the Thyroid Gland 290 

Therapeutic Test of Hypofunction 292 

The Parathyroid Gland 292 

The Thymus Gland 293 

The Suprarenal Glands 295 

Hypofunction of the Suprarenal Glands 296 

Sugar Tolerance and Hypoadrenal Function . . . 298 

Hyperfunction of the Suprarenal Glands 299 

Adrenalinemia and Hyperadrenalism 300 

Adrenalin Glycosuria and Hyperfunction 301 

Complement-fixation in Suprarenal Disease 302 

The Hypophysis 302 

States of Hyperpituitarism 304 

Increased Gas Exchange and Hyperpituitarism . . 305 

Glycosuria and Hyperpituitarism 306 

States of Hypopituitarism 307 

The Vegetative Nervous System 307 

Vagotonia and Sympathicotonia 308 

Vagotonia 309 

Sympathicotonia 309 

The Oculocardiac Reflex Test of Ashner 309 

Pilocarpine Test 310 

Adrenalin Test 311 

Index 313 



MANUAL OF VITAL FUNCTION 
TESTING METHODS 



MANUAL OF VITAL FUNCTION 
TESTING METHODS 

CHAPTER I 
TESTS OF LIVER FUNCTION 

GENERAL CONSIDERATIONS 

The liver cell represents the whole organ in minia- 
ture. If we possessed an adequate knowledge of all 
the functions of this cell, we would understand com- 
pletely the functions of the organ. 

The functions of the liver cell are numerous and each 
individual cell performs its quantitative quota of all 
these functions. The liver is provided with two evacu- 
ating channels, one internal, by way of the blood (he- 
patic vein), the other external, by way of the biliary 
passages. It receives blood by way of the portal vein 
from the digestive tract and its related organs, and dis- 
charges into the duodenum its more or less complex 
excretion. 

Regarded as a center of elaboration, the liver cell 
has several important functions, chief of which are: 
1. ureagenetic, 2. glycogenetic, 3. lipasic, 4. antitoxic or 
cytopexic, 5. sanguinopoietic, 6. thermic, 7. ferric. 
The above mentioned functions are spoken of as en- 
docrinous. The liver has, however, an exocrinous func- 
tion which by some is regarded as the most character- 
istic, namely, the excretion of bile by way of the biliary 
passages. 

Tests of hepatic function are directed towards the de- 
termination of the integrity of one or the other of 
these phases of activity. 

15 



16 Manual of Vital Function Testing Methods 

There is no organ whose functional and clinical ex- 
amination is fraught with more difficulties than the liver. 
Slight functional disturbances of the organ are attended 
by very uncertain symptomatology. When severe or- 
ganic lesions exist, such as acute yellow atrophy, cirrho- 
sis, abscess, cancer, etc., modifications in the size of 
the liver, as well as its consistence, together with 
symptoms of portal hypertension (ascites) and of bili- 
ary obstruction (icterus), offer a combination of objec- 
tive evidence which makes the diagnosis usually clear. 

But there is a longer or shorter period in all these 
diseases, usually in the earlier stages during which a 
condition of hepatic insufficiency (hypohepatism) and 
more rarely, hepatic hyperfunction (hyperhepatism) 
exists, which might be recognized by appropriate tests. 
The trend of modern investigation is in the direction 
of the development of practical functional tests of 
sufficient simplicity to enable the clinician to judge the 
functional capacity of the liver, before gross organic 
lesions or indubitable symptoms have appeared. 

Tests for liver functional capacity may be profitably 
considered under five headings. 1 The first four are 
endocrinous, the fifth exocrinous. They are as follows : 
I. Disturbance of the glycogenic function. II. Dis- 
turbance of the ureagenetic function. III. Disturbance 
of the antitoxic function. IV. Disturbance of the 
hemapoietic function. V. Disturbance of the biliary 
function. 

I. FUNCTIONAL TESTS TO DETERMINE DISTURBANCES OF 
THE GLYCOGENIC FUNCTION OF THE LIVER 

Normally the liver cells retain in the form of glycogen 

almost all the glucose brought to them from the ali- 

*See Les Procedes actuel d'etude de l'insuffisance hepatique. 
Gaz. d. hop. Par. 1914, no. 25, p. 408 (Brule, Garban). To this 
article is appended an extensive bibliography. 



Tests of Liver Function 17 

mentary tract. Under certain conditions of liver in- 
sufficiency, glucose is not fixed by the cells, and passes 
immediately into the blood, producing a hyperglycemia, 
from whence it is excreted in the urine. This fact has 
been utilized as a basis for testing the glycogenetic 
integrity of the liver cell. 

The name of Claude Bernard is closely linked with 
the history of the physiology of hepatic glycogenesis. 
Soon after the discovery by Claude Bernard of the role 
of the liver in carbohydrate metabolism, the use of 
sugars as tests for hepatic function began. 

In applying the sugar test, different varieties of 
sugars have been employed, particularly saccharose 
(cane sugar), glucose, levulose, and galactose. The 
first sugar employed for this purpose was saccharose 
(cane sugar). 

The sugar tests of hepatic function are four in 
number, as follows: 1. The Cane Sugar test. 2. The 
Glucose test. 3. The Levulose test. 4. The Galactose 
test. 

1. The Cane Sugar Test. Coir at, Lepine Test 

150 to 200 grams of cane sugar syrup are adminis- 
tered to the subject in the morning while fasting. The 
urine is collected every hour or two and examined for 
sugar with Fehling's solution or other means. The 
presence of glycosuria renders the test positive. 

The cane sugar test was considered for a long time 
the best criterion of liver insufficiency. The clinical 
results of the test have, however, been contradictory. 
A rather weighty theoretical objection is the fact that 
cane sugar must be converted into glucose in the ali- 
mentary tract before it can be utilized by the organism, 
and the power of the intestinal juices to produce this 



18 Manual of Vital Function Testing Methods 

conversion is in each case an unknown quantity and 
therefore a source of error. 



S. The Glucose Test 

The patient takes in the morning on an empty stom- 
ach, 150 grams of pure dextrin-free glucose dissolved 
in 300 c. c. of water. The ingestion of this amount 
should not take over a quarter of an hour. 

The urine is then collected every hour or two for ten 
hours in separate vessels and tested for sugar, the 
patient remaining on a milk diet during the time re- 
quired by the test. 

Castaigne has advised the following details with a 
view of perfecting the glucose test. For several days 
prior to the performance of the test, the subject should 
be kept on a certain known quantity of carbohydrate. 
The renal permeability should be investigated and the 
possibility of spontaneous glycosuria especially after 
meals eliminated. 

The results of the glucose test have been rather con- 
flicting and some investigators have appeared to find 
glycosuria following the test in apparently healthy sub- 
jects and its absence in certain cases of hepatic cirrhosis 
where the liver parenchyma would have been acknowl- 
edged on general clinical grounds to have been damaged. 

8. The Levulose Test. Strauss Test 

This test was introduced by Strauss 2 in 1901 as a 
substitute for the saccharose and glucose tests. 

a Berl. klin. Wchnschr., 1898, XXXV, p. 398, and 1899, XXXVI, 
p. 159; Deutsch. med. Wchnsch., 1901, XXVII, p. 756, also 1903, 
XXXIX, p. 1780. 



Tests of Liver Function 19 

To apply the test 100 grams of levulose are given in 
the morning on an empty stomach and the urine evacu- 
ated every four hours thereafter for a day and examined 
for sugar by the fermentation test or polariscope. 

Owing to the high price of levulose, honey, which 
contains a large percentage of it, has been advised as a 
substitute. 

A normal person should tolerate 100 grams of levu- 
lose without levulosuria. 

The rationale of this test was founded on the experi- 
mental work of Sachs, 3 who found that frogs whose 
livers had been removed had a lower tolerance for levu- 
lose than intact controls. With dextrose and galactose 
this was not the case. It was contended therefore that 
there is no mechanism besides the liver capable of 
handling levulose, while there is such an extra hepatic 
mechanism in the case of glucose. 

Immediately after its introduction, this test came 
into pretty general use and was commended by Ferra- 
nini 4 v. Halasz, 5 Bruining, 6 and others, and was con- 
demned by Landsberg, 7 Churchman, 8 and others. Much 
was expected from the levulose test because as above 
stated it was believed that the liver alone is concerned 
in levulose metabolism. However this may be, experi- 
ence has apparently failed to substantiate the hopes 
which the test originally inspired and it is not now be- 
lieved that the levulose test is essentially superior to 
other sugar tests of hepatic function. 

"Zeitschr. f. klin. Med., 1899, XXXVIII., p. 87. 
4 Zeitschr. f. inn. Med., 1902, XXIII, p. 921. 
6 Wien. klin. Wchnschr., 1908, XXI, p. 44. 
8 Berl. klin. Wchnschr., 1902, XXXIX, p. 587. 
7 Deutsch. med. Wchnschr., 1903, XXIX, p. 563. 
8 Johns Hopk. Hosp. Bull., 1912, XXIII, p. 10. 



20 Manual of Vital Function Testing Methods 



J^. The Galactose Test. Bauer's Test 

Forty grams of milk sugar dissolved in 400-500 c.c. 
of tea are taken in the morning on an empty stomach. 
The urine is passed every four or five hours thereafter 
and examined for sugar. 

In icterus gravis and catarrhal jaundice this test has 
been reported as giving fairly constant results. 

Bauer 9 considered the galactose test especially 
adapted to determining the condition of liver function in 
catarrhal jaundice. The amount of sugar recovered 
in the urine after the galactose test was found to be 
greater in catarrhal jaundice than in obstructive jaun- 
dice, consequently it was supposed that the test would 
be of importance in differential diagnosis between the 
two conditions. This opinion was upheld and confirmed 
by Bondi and Konig, 10 Riess and Jehn, 11 and Hi- 
rose. 12 

Outside of catarrhal jaundice the results were pro- 
nounced inconstant by Falk and Saxl, 13 v. Frey, 14 and 
others. 

Conclusions concerning the Sugar Tests. — -It may be 
said that the investigation of hepatic insufficiency by 
any or all of the sugar tests, is to be regarded merely as 
supplementary or complementary to other means of 
investigation, since the results of these tests alone are 
not conclusive. Nevertheless the results which may be 
obtained by their help when associated or corelated with 

8 Wien. med. Wchnschr., 1906, LVI, p. 2557. 
10 Wien. med. Wchnschr., 1910, LX, p. 2617. 
u Deutsch. med. Wchnschr., 1912, XXXVIII. 
12 Deutsch. Arch. f. klin. Med., 1912, CVIII, p. 187. 
13 Ztsch. f. klin. Med., 1911, LXXIII, p. 131, 325. 
"Ztschr. f. klin. Med., 1911, LXXII, p. 383. 



Tests of Liver Function 21 

those obtained by other methods are of sufficient value 
to justify their retention in clinical medicine. 

It is now understood that the mechanism whereby 
alimentary glycosuria is produced is more complex than 
was formerly supposed, and that the liver is not the 
only organ involved in the process. Other tissues are 
now known to be concerned in glycofixation and mobil- 
ization. Furthermore, the individual coefficient of sugar 
utilization has been found to vary within quite wide 
limits, 50-350 grams of levulose for example. The co- 
efficient varies also in the same individual for the dif- 
ferent sugars so that in reporting results of sugar tests 
it is deemed expedient to specify the particular kind of 
sugar used. 

The unknown factors of intestinal absorption and 
renal permeability complicate all sugar tests. 

The sugar tests have been found positive, especially 
in severe bivenous cirrhosis, in icterus gravis and in 
cholelithiasis. They are, however, of no prognostic 
value. 

A recent comprehensive study of the applicability of 
carbohydrates as tests for hepatic functional activity 
has been made by Bloomfield and Horwitz. 15 These 
authors call attention very properly to the factors 
which tend to render the sugar tests for hepatic func- 
tion unreliable. The great theoretical stumbling block 
in the way of accepting the finding of the carbohydrate 
tests is the fact that extra-hepatic factors of consider- 
able importance are concerned in the sugar regulating 
metabolism. Some of the glands of internal secretion 
take part in this. Certain lesions of the hypophysis 
may cause glycogenolysis and glycosuria, while with 
other hypophyseal lesions the sugar tolerance is in- 

15 Johns Hopk. Hosp. Bull., 1913, XXIV, p. 375:— a good bibli- 
ography is appended to this article. 



22 Manual of Vital Function Testing Methods 

creased. 

The internal secretion of the pancreas is generally 
considered to exert an inhibitory effect on the mobiliza- 
tion of glycogen by the liver. The suprarenals have an 
accelerating effect on the same mechanism. The thy- 
roid gland also takes part in sugar metabolism, the 
exact nature of which is unknown. Both the autonomic 
and sympathetic nerves likewise affect the mobilization 
of glycogen. These last facts, of course, tend to render 
the sugar tests less definite and satisfactory. 

From a practical standpoint it cannot be denied that 
the sugar tests have certain disadvantages. It is diffi- 
cult for patients to ingest the large quantities of sugars 
required without the occurrence in certain cases of 
nausea, vomiting and diarrhoea. Faulty absorption, 
intestinal fermentation, portal obstruction with col- 
lateral circulation, sugar retention due to nephritis, 
inconstancies in the diet also combine to render the 
results inaccurate. 

It will remain for the future, however, to determine 
whether the sugar tests of hepatic insufficiency can be 
developed or modified in such a way that the rather 
numerous objections with which impartial observers are 
agreed the tests are encumbered, may be eliminated. 
In such an event these tests, which from an historical 
standpoint are so interesting, may take a definite place, 
even though subsidiary, in that important group of 
tests by which one seeks to obtain an insight into the 
functional integrity of the liver. 

n. FUNCTIONAL TESTS TO DETERMINE DISTURBANCES OF 
THE UREAGENETIC FUNCTION OF THE LIVER 

All the tests for hepatic function which deal with 
the ureagenetic activity of the liver are concerned with 



Tests of Liver Function 23 

the question of nitrogen metabolism. The liver plays a 
large and important part in this metabolism; perhaps 
not so exclusive a role, however, as was formerly sup- 
posed. 

The ureagenetic function tests are, for the most part, 
merely studies of nitrogen metabolism. They consist 
mostly of estimations of the amount of nitrogen elimi- 
nated in the urine with accurate partition of this nitro- 
gen into different groups, particularly urea and am- 
monia. The relation between the amount of nitrogen 
eliminated in these two forms when compared with the 
total nitrogen eliminated will afford valuable criteria 
for estimating the ureagenetic functional capacity of 
the liver. 

The practical estimation of ureagenetic functional 
capacity of the liver involves much more complex series 
of chemical processes than were found to be involved in 
the investigation of the carbohydrate function by means 
of the sugar tests. Inasmuch as the first criterion of 
normal liver function from the standpoint of nitrogen 
metabolism involves the relation between the amount of 
urea excreted in the urine and the amount of total 
nitrogen excreted, therein, the investigator must make 
two separate chemical analyses. First the exact amount 
of urea excreted must be estimated, and second, the 
exact amount of total nitrogen eliminated. In discuss- 
ing these analyses, no attempt will be made to give any 
data beyond the description of such methods which, on 
account of their comparative simplicity and established 
accuracy, have become firmly established in the clinic. 
The estimation of total nitrogen in the urine by the 
standard method — that of Kjeldahl — requires a good 
deal of time and some technical skill. But it is a method 
which can be easily performed in any well-equipped 
laboratory attached to a hospital, and should be car- 



24 Manual of Vital Function Testing Methods 

ried out by a competent person. A rapid and accurate 
method of quantitative estimation of urea has been 
lately devised — that of Marshall — and this method has 
already become the standard one in the clinic. 

The estimation of urinary ammonia, or ammonia 
nitrogen, is another step required in the study of the 
efficiency of the liver from the standpoint of nitrogen 
metabolism. Here also it is best for the clinician to 
familiarize himself with one method, preferably that of 
Folin, the details of which are further on discussed. 

The actual administration of ammonium-bearing or 
amino-acid-containing substances to the patient, with 
the subsequent examination of the urine to determine 
the capacity of the liver to convert these substances into 
urea, is another method of clinical investigation of the 
liver function. Finally it is conceded that the estima- 
tion of rest or residual nitrogen in the blood serum may 
be utilized to determine whether or not the liver cell is 
capable of producing an adequate urea synthesis of 
nitrogen products in the body. 

To recapitulate, we may tabulate the different meth- 
ods of testing the ureagenetic functional power of the 
liver under the following heads and in this order they 
will be discussed: 1. Urea Elimination and Nitrogen 
Coefficient as Criteria of Ureagenetic Liver Function; 
2. Augmentation of Urinary Ammonia as an Index of 
Ureagenetic Liver Function; 3. Amino-aciduria as a 
Criterion of Ureagenetic Liver Function; 4. Estima- 
tion of Residual Nitrogen in the Blood Serum as an 
Index of Ureagenetic Liver Function. 

1. Urea Elimination and Nitrogen Coefficient as 
Criteria of Liver Function 

Urea Elimination. — The liver has long been regarded 
as the chief source of urea, which substance is supposed 



Tests of Liver Function 25 

to be formed from ammonium salts, amino acids and 
products of nitrogenous catabolism. 

The urea synthesis is supposed to be the work of the 
liver cell governed by ferments which it secretes. 

It has long been recognized that in certain diseases of 
the liver the percentage of urea eliminated in the urine 
is lowered. Therefore diminution of urea excretion 
may sometimes indicate hepatic insufficiency and an 
estimation of the quantity of urea eliminated is there- 
fore an available factor in testing the ureagenetic func- 
tion of the liver cell. 

The quantity of urea eliminated in the urine by a 
healthy adult in 24 hours is 25 to 30 grams. In cases 
of hepatic insufficiency this quantity may fall to 10, 5, 
3 or .5 grams or even in icterus gravis. 

But before one can attribute a diminution of urea 
elimination to functional disorder of the liver, certain 
other factors of great importance must be taken into 
consideration. One of these is the functional capacity 
of the kidney. It is well understood that urea retention 
in the blood may be due to defect of kidney permeability. 

Another important factor is the amount of proteid 
intake. Before attempting to draw any conclusions 
with respect to the relation of urea elimination to the 
ureagenetic functional capacity of the liver it will al- 
ways be necessary that the individual to be tested shall 
be placed for a sufficient length of time upon a fixed 
ration in which the amount of proteid is known and 
invariable. 

The Nitrogen Coefficient. — The relation of urea ni- 
trogen to the total nitrogen excreted in the urine is 
known as the coefficient of nitrogen elimination. This 
coefficient may be important since under certain circum- 
stances its diminution may constitute a valuable sign 
of ureagenetic hepatic insufficiency. 



26 Manual of Vital Function Testing Methods 

The nitrogen coefficient is usually expressed by the 
following fraction: 

N. urea 



N. total 



the arithmetical relation in other words between the 
amount of nitrogen eliminated in the urine as urea and 
the total quantity of nitrogen eliminated. This co- 
efficient will diminish in proportion to the diminution 
of urea nitrogen. 

According to some authors a diminution of the ni- 
trogen coefficient is absolutely constant in hepatic in- 
sufficiency. 

The normal figures of the nitrogen coefficient vary 
from 85% to 95%. In icterus gravis it has been found 
reduced to 40; likewise in phosphorus poisoning. 

But just as in estimating the percentage of urea in 
the urine and considering the same as an index of he- 
patic function, so also in determining the coefficient of 
nitrogen elimination for the same purpose the patient 
must be placed on a fixed and invariable proteid regi- 
men, though the absolute quantity of proteid taken is 
negligible. 

It must also be previously known that there is no 
deficiency in renal permeability. To determine the co- 
efficient of nitrogen elimination, two operations must be 
performed. First, a quantitative estimation of urea 
must be made, from which the calculation of urea nitro- 
gen may readily be accomplished. Secondly, the total 
nitrogen eliminated in the urine must be estimated and 
this part of the operation is, unfortunately, somewhat 
difficult and time-consuming. The simplest known 
means for performing these operations will be given. 

Quantitative Estimation of Urea in Urine. — Several 



Tests of Liver Function 27 

methods are in use for determining quantitatively the 
amount of urea in urine. One of the most frequently 
used is the hypobromite method, using the ureometer of 
Doremus. In this method nitrogen is set free by sodium 
hypobromite and measured in the apparatus. The re- 
sults obtained by this method are extremely inaccurate 
and it is not used, therefore, where absolute results are 
required. 

Three other methods which are much more depend- 
able have been in use for some years in the laboratories. 
These are: 1. The Morner-Sjoqvist; 16 2. Folin's 
method; 17 and 3. Schondorff's method. 18 The details of 
these methods may be found in any modern text book 
on laboratory methods. We shall not give a descrip- 
tion of them here. 

Mar shall 9 s Method of Urea Estimation. — Quite re- 
cently a rapid chemical method for the estimation of 
urea in urine has been introduced by Marshall of Johns 
Hopkins. 19 It depends upon the conversion of urea into 
ammonium carbonate by means of an enzyme prepared 
from soy bean. This enzyme is called urease because of 
its facility in effecting this conversion. Urease is found 
in some bacteria and fungi. The following formula 
represents the chemical decomposition produced : 



NH 2 


ONH 4 


CO +2H 2 = 


CO 


NH 2 


ONH 4 



The presence of urease in soy bean (glycine hispida) 
was first observed by Takeuchi in Japan. Its applica- 

18 Skand. Arch. f. Phys., 1891, II, p. 438; Zeit. f. phys. Chem., 
XVII, p. 140. 

"Zeit. f. phys. Chem., 1901, XXXII, p. 504. 
18 Arch. f. d. Ges. Phys., 1896, LXII, p. 1. 
18 Jour, of Biol. Chem., 1913, XIV, no. 3; 1913, XV, no. 3. 



28 Manual of Vital Function Testing Methods 

tion to the quantitative estimation of urea is due as 
above stated to Marshall, 

A convenient form of the enzyme urease is now to 
be found upon the market under the name of urease 
(Dunning). It is supplied in convenient 25 milligram 
tablets put up 40 tablets per package by Hynson West- 
cott & Co., pharmaceutical chemists of Baltimore, 
Maryland. 

Urease (Dunning) is a fine, almost white, powder, 
with little taste or odor, soluble in slightly alkaline 
water. 

The apparatus and material required for the estima- 
tion are as follows: Four 200 c.c. Erlenmeyer flasks 
with cork stoppers ; one 50 c.c. glass-stoppered burette ; 
one 5 c.c. bulb pipette; one small glass mortar; 100 c.c. 
of solution of methyl orange; 1000 c.c. of decinormal 
solution of HC1; 50 c.c. toluol and a package of urease 
(Dunning) tablets. 

Put 1 or 2 c.c. of toluol into each of two Erlenmeyer 
flasks of 200 c.c. capacity. Into one of the flasks intro- 
duce exactly 5 c.c. of a specimen of urine and 100 c.c. 
of distilled water; stopper flask with cork. Crush a 
urease tablet in a small glass mortar and dissolve in 
about 5 c.c. of water. Transfer this solution without 
loss into the other flask containing toluol and rinse 
mortar with several portions of distilled water until 
about 100 c.c. have been added to the contents of the 
second flask. Add 5 c.c. of the urine and stopper with 
a cork. 

Each flask is now thoroughly shaken and allowed to 
stand at room temperature over night or at least 8 
hours. If it is necessary to get more rapid estimations 
two tablets are used instead of one and the mixture 
digested at 40 °C for an hour. 

The test may indeed be completed in 15 minutes by 



Tests of Liver Function 29 

using only 1 c.c. of urine, two tablets and digesting at 
40° Centigrade for 15 minutes. The factor would in 
this case be 3 instead of .6, as will be seen later by 
carrying out the longer time limit. 

After the lapse of the time set the two solutions are 
titrated to a distinct pink color with decinormal HC1, 
using methyl orange as indicator. 

The urease has converted the urea present in the urine 
into ammonium carbonate. The amount of ammonium 
carbonate formed by the urease is indicated by the 
quantity of standard HC1 solution required to ex- 
actly neutralize the contents of the flask containing 
urease minus the quantity required for control speci- 
men. 

According to the chemical formula representing the 
conversion of urea into ammonium carbonate (v. s.) it 
may be seen that 60 grams of urea are converted (by 
urease) into 96 grams of ammonium carbonate. This 
amount (96 grams) of ammonium carbonate would 
require 72 grams of standard HC1 solution to neu- 
tralize it. 

As this quantity of HC1 solution (72 grams) is con- 
tained in 20,000 c.c. of n/ 10 HC1 solution and is 
equivalent to 60 grams of urea represented by 96 grams 
of ammonium carbonate, then 1/20000 of the quantity 
of 1 c.c. of n/io HC1 solution will be equivalent of 
1/20000 of 60 grams, equal .003 (60-^-20000=.003). 

Therefore each c.c. of decinormal HC1 solution re- 
quired to neutralize the enzyme treated specimen minus 
the number of c.c. required to neutralize the control 
specimen represents .003 of urea, and as the 5 c.c. speci- 
men is the V200 part of a liter, multiply the number of 
c.c. of n/ 10 HC1 solution in excess of the control re- 
quirements by the factor .6 (.003X200=.6) to find the 
urea per liter when estimating the daily output. 



30 Manual of Vital Function Testing Methods 

One part of nitrogen is equivalent to 2.143 parts of 
urea. 



Determination of Urea in Urine — Van Slyke's Method. 
— 1. One-half c.c. of urine is measured into tube A 
(see illustration). Add 1 c.c. of a 10 per cent, solu- 



air from 
wtshbottW 




M M 




Standard 
acid 



Apparatus for determining the urea content by means of urease. 



tion of Urease (or 1 tablet, which will quickly disinte- 
grate and dissolve), and then 5 c.c. of water. 

2. Add 2 drops of caprylic alcohol, to prevent 



Tests of Liver Function 31 

foaming. Close with the stopper. Allow to digest 15 
minutes at 20° C, or for a shorter time if the tempera- 
ture is between 20° C. and 50° C. 

3. Measure 25 c.c. of N/50 hydrochloric or sul- 
phuric acid into tube B, add 2 drops of caprylic alco- 
hol, and then 1 drop sodium alizarinsulfonate as indi- 
cator. Connect the tubes as shown. 

4. When digestion is complete, an air current is 
passed for a half minute to sweep over into B any small 
amount of ammonia which, during digestion, has es- 
caped into the air-space of tube A. 

5. Open A and add 4 to 5 gm. of potassium car- 
bonate. 

6. Pass an air current rapidly through the tubes 
until all ammonia has been carried over into the acid in 
B. (The time required depends on the rate of aeration, 
which varies from five minutes to a half hour.) 

7. When aeration is complete, the excess of acid in 
B is titrated with N/50 sodium hydroxide. 

8. The difference in c.c. of N/50 acid represents 
the urea plus ammonia nitrogen of the urine sample. 

9. To determine the ammonia nitrogen alone, meas- 
ure 5 c.c. of urine into A. Add potassium carbonate 
at once and aerate as before. Titrate the excess of acid 
as in paragraph 7. 

Calculation of Result. — The number of c.c. of N/50 
acid neutralized in operation 9, divided by ten, and sub- 
tracted from that neutralized in operation 7, repre- 
sents the N/50 acid neutralized by the urea nitrogen 
alone in 0.5 c.c. of urine. 

This result multiplied by 1.2 gives the number of 
grams of urea contained in 1,000 c.c. of urine. 



32 Manual of Vital Function Testing Methods 

For example: 

N/50 acid neutralized by 0.5 c.c. urine 

(No. 7) = 9.50 c.c. 

N/50 acid neutralized by 5.0 c.c. urine 

divided by 10 (No. 9) . . . = .36 " 

N/50 acid neutralized by 0.5 c.c. urine 

alone = 9.14 * 

Result: 9.14 X 1.2 — 10.96 grams of urea per 1,000 

c.c. of urine. 



Determination of Urea in Blood, Spinal Fluid, Etc. 
— Van Slyke's Method. — "Urease is particularly valu- 
able in permitting a simple and accurate determination 
of urea in the blood because its action is so specific that 
it attacks none of the other constituents." 

The blood when drawn is mixed with 1 per cent, of 
dry potassium citrate (or the equivalent in citrate so- 
lution), to prevent clotting. 

Three c.c. of the blood or fluid are mixed with 1 c.c. 
of the Urease Solution (or one soluble tablet added). 
Add 5 c.c. of water, then 5 drops of caprylic alcohol 
to prevent foaming. Allow to digest for ten minutes 
at 40° C. Measure 15 c.c. (mils) of N/100 acid into 
tube B. Proceed as for analysis of urine, except that 
the titration is made with N/100 NaOH. 

Calculation of the Result. — Each c.c. of N/100 acid 
neutralized corresponds to 0.01 per cent, of urea. 

Grams of urea per 100 c.c. (mils) of blood = 0.01 
X c.c. of N/100 acid. 

Urea nitrogen per 100 c.c. of blood = 0.00466 X 
c.c. of N/100 acid. 



Tests of Liver Function 33 



USEFUL REFERENCES TO LITERATURE ON UREASE 

D. D. Van Slyke and G. E. Cullen, Proc. Soc. Exp. 

Biol, and Med., 1913, Dec. 17; Proc. Soc. Biol. 

Chem., 1913, Dec. 29; Journ. Biol. Chem., 1914, 

Vol. XIX, pp. 141, 211; 1916, XXIV, p. 117. 
D. D. Van Slyke and Gotthard Zacharias, Journ. Biol. 

Chem., 1914, Vol. XIX, p. 181. 

Estimation of Total Nitrogen in the Urine. Kjel- 
dahVs Method. 20 — Ten c.c. of urine are carefully meas- 
ured into a Jena glass, round-bottom flask. Add a few 
drops of concentrated solution of sulphate of copper, 
15 c.c. of H 2 S0 4 and 10 grams of potassium sulphate. 

The flask is supported in an inclined position to pre- 
vent loss by spurting. The mouth of the flask is loosely 
closed by a glass bulb blown on end of a piece of glass 
tubing. 

The flask may be conveniently supported by a thick 
piece of asbestos board with a hole in the center of a 
size to permit the flame to come in contact only with the 
portion of flask covered by fluid. Wire gauze protects 
the flask from direct contact with the flame. 

The flask should now be gently heated over a Bunsen 
flame for half an hour. When foaming ceases the flame 
is raised until the acid begins to boil gently. The whole 
heating process is carried out under a hood because of 
sulphurous acid fumes which are given off. When the 
fluid in the flask is colorless or pale green, oxidation is 
complete. This requires about two hours. The acid 
and the oxidizer (CuS0 4 ) convert all nitrogenous mat- 
ter into ammonium sulphate. The flask is then cooled. 
The next step is distillation. The same or a larger 

"Zeit. f. Chem., 1883, XXII, p. 3T8. 



34 Manual of Vital Function Testing Methods 

Jena glass flask may be used, but preferably a copper 
apparatus which will not break. Two hundred c.c. of 
water are added and enough 30% NaOH solution to 
make the mixture strongly alkaline. Ammonia is set 




KjeiDML Apparatus 



free by the action of the alkali. This is distilled over 
in 80 c.c. of decinormal H 2 S0 4 , which has been accu- 
rately measured into a flask. The flask containing the 
original solution is heated until about 2/3 of it have 
passed over and there is considerable bumping from 
the separation of sodium sulphate. This usually re- 
quires about thirty minutes. Bumping may be dimin- 
ished by adding fragments of pumice, granulated zinc 
or talcum powder at the beginning of distillation. A 
simple form of apparatus can be extemporized in the 



Tests of Liver Function 35 

laboratory. [See Illustration on page 34.] 

The tube D contains a few glass beads and some of 
the H 2 S0 4 is poured over these to prevent the escape of 
any ammonia. A few drops of methyl orange are 
added to the pearls and the flask C to indicate alkalin- 
ity, in which event more acid is to be added promptly. 
D is not necessary if a Liebig condenser is used. 

The tube B prevents the alkaline fluid in A from 
spurting over into E. The tubes E and B are made of 
broken pipettes of 50 or 100 c.c. capacity. 

The decinormal acid into which the ammonia has 
condensed is titrated with n/ 10 NaOH. Methyl orange 
is used as an indicator. 

Subtract the number of c.c. of decinormal NaOH 
used from the number of c.c. of acid taken and the 
remainder will give the amount of ammonia distilled 
over, for every c.c. of acid neutralized by the ammonia 
is equivalent to so much decinormal ammonia. 

Decinormal ammonia contains 1.4 grams of nitrogen 
to the liter or .0014 gram per one c.c. The amount 
of nitrogen can therefore be determined by multiplying 
the number of c.c. of acid neutralized by .0014. This 
gives the nitrogen in grams for 10 c.c. of urine used. 

The description of the method given above is taken 
from Wood's Chemical Diagnosis, N. Y., 1909, p. 408. 

#. Augmentation of Urinary Ammonia as an Index of 
Ureagenetic Liver Function 

Ammonia, amino acids and carbonates constitute the 
last intermediaries in the metabolic processes by which 
the body proteids are catabolized into urea. As before 
stated, the liver has been regarded as the chief factor in 
this conversion. 



36 Manual of Vital Function Testing Methods 

If the functional capacity of the liver is deficient, 
the amount of nitrogen eliminated in the form of am- 
monia will be increased. Normally, .7 gram of am- 
monia are excreted by the urine in 24 hours. In hepatic 
insufficiency the amount may be doubled or trebled. 

The relation of ammonia nitrogen to total nitrogen 
in the urine is normally 3 or 4 parts per hundred. 
Under pathological conditions, however, it may rise to 
30 parts per 100 and such an increase may, under cer- 
tain circumstances, indicate hepatic insufficiency. In 
states of acidosis the ammonia nitrogen is also increased. 

It is often useful to make a comparison between the 
amount of nitrogen excreted as ammonia and the nitro- 
gen eliminated as urea. This is done as follows: The 
molecular weight of ammonia NH 3 is 17, the nitrogen 
fraction of ammonia is, therefore, 14 /i7- 

NH 2 

The molecular weight of urea CO is 60. 

NH 2 

The nitrogen fraction is 28 / 60 or 7 /i 5 . 

The amount of ammonia in grams in a given sample 
is estimated by the formalin method (v. s.), and 14 /i7 
of this represents the ammonia nitrogen. The urea is 
calculated in grams in the same sample of urine, by 
Marshall's method, and 7 / 15 of the weight is nitrogen. 
Under normal conditions the ammonia nitrogen is about 
V20 °f the urea nitrogen. 

Estimation of Ammonia Nitrogen in the Urine. The 
Formalin Method. — The estimation of acidity is the 
first stage in the estimation of ammonia nitrogen. Pro- 
ceed as follows : 

Measure out 25 c.c. of urine into a beaker and dilute 
with about double the volume of distilled water. Add 
2 or 3 drops of phenolphthalein. Run in n/ 10 NaOH 
from a burette until a faint permanent pink color is 



Tests of Liver Function 37 

produced. Note the number of c.c. of NaOH used. 
Measure about 10 c.c. of commercial (40%) formalin 
into a second beaker. Add phenolphthalein. Neutral- 
ize exactly with n/ 10 NaOH. Add the neutral formalin 
to the neutral urine. The pink color disappears. Run 
in n/ 10 NaOH until the pink color returns. Note the 
number of c.c. of NaOH used. The result is calculated 
in terms of n / 10 NaOH for the acidity. That is to say 
the acidity of the urine is given as the number of c.c. of 
n/ 10 NaOH required to neutralize 100 c.c. of urine to 
phenolphthalein. Thus if 10 c.c. of soda were used in 
the first titration to neutralize 25 c.c. of urine, the acid- 
ity of the urine is 10 / 25 X 100=40. The ammonia re- 
sult should be expressed in grams of ammonia per 24 
hours. The number of c.c. of soda used in the second 
titration of the urine is the equivalent of the number of 
c.c. of ammonia present in the 25 c.c. of urine. Sup- 
posing the number of c.c. of soda used in the second 
titration to have been 10, then 10 c.c. n/ 10 NaOH= 
10 c.c. n/ 10 NH 3 = 10 X .0017 gm. NH 3 . Therefore the 
ammonia passed in the 24 hours = 10 X .0017 X 
24 hours urine in c.c. 



25 

The reaction depends upon the combination of the am- 
monium salts with formaldehyde to form urotropine 
and the consequent liberation of the acids previously 
combined with ammonia. 

Experimental Provocative Ammoniuria. — This test 
is based upon the fact that normally, the liver trans- 
forms all ammonia transported to it into urea. If there 
is pathological alteration of the liver cell, this am- 
monia will not be transformed and the quantity of 
ammonia in the urine increases. 

Before applying the test of provocative ammoniuria 



38 Manual of Vital Function Testing Methods 

in a given case the total ammonia excretion in 24 hours 
should be estimated over two days. Meanwhile the 
patient is put upon a fixed regimen. 

In the morning, after having urinated, the subject is 
given 6 grams of ammonium acetate. The urine for the 
next 24 hours is collected and the ammonium content 
estimated (v. s.) which can be compared with that 
found prior to the test. 

The value of this test is variously estimated. Some 
have concluded that any considerable increase of am- 
monia in the urine after the ingestion will always in- 
dicate an impairment of the functional integrity of the 
liver cell. It is only claimed to be of value when posi- 
tive. Others, on the contrary, have insisted that in spite 
of very advanced disease of the liver the ammonium 
salts ingested continue to be transformed into urea. 

3. Aminoaciduria as a Criterion of Ureagenetic 

Function 

The existence of considerable quantities of amino 
acids, leucine and tyrosine, in the urine in liver diseases 
was noted in 1866 by Frerichs. In 1907 Glaessner 21 
showed that in disease of the liver there is usually an 
increase in the relation of amino nitrogen to total nitro- 
gen in the urine. Normally this relation, or so called 
coefficient, of aminoaciduria has been shown to vary 
from .5 to 3.5 per 100. In diseases of the liver (chole- 
lithiasis, cirrhosis), the ratio may rise to 11 or even 13 
per 100. 

Labbe and Bith have estimated the amount of amino 
acids in the blood serum and have found it increased in 
certain liver diseases. 

Hyperaminoaciduria, according to Brille and Gar- 

21 Zeit. f . Exper. Path. Therap., 1907, IV, p. 336. 



Tests of Liver Function 39 

ban, 22 is not necessarily an indication of liver disease. 
It may occur during states of rapid emaciation, cach- 
exia, pneumonia, typhoid fever and diabetes compli- 
cated with acidosis. 

These authors agree, however, that in all these states 
it may not be improbable that the appearance of am- 
inoaciduria is dependent upon a disturbance of the 
function of the liver cell. 

Provocative Aminoaciduria. — The principal sub- 
stances which have been used are glycocol, alanin, as- 
paraginic acid, and commercial peptone. These amino 
acids, also peptone, have been employed by different 
experimenters. 23 The patient is given certain quanti- 
ties of these substances and the amount of amino-acid 
excreted in the urine carefully measured. 

If the proper care has been taken in the days which 
precede the test to establish the normal amino nitrogen 
coefficient for the individual and to keep the subject 
under observation upon a fixed and invariable diet, then 
provocative aminoaciduria tests may be of value. They 
will frequently show a marked increase of the coefficient 
after the ingestion of the amino-acids (or peptones) 
as compared with the coefficient prior to the test, and 
the marked increase according to some authors will 
only occur when the liver parenchyma is diseased. 

The insuperable difficulty in these methods of esti- 
mating liver function arises from the fact that the esti- 
mation of amino nitrogen in urine and blood requires 
very complicated chemical manipulations which effectu- 
ally prevent their introduction into clinical medicine. 

22 Gaz. d. Hdp., 1914, LXXXVII, p. 405. 

^Ztschr. f. klin. Med., 1910, LXXI, p. 261; 1911, LXXIII, p. 
325. 



40 Manual of Vital Function Testing Methods 

I±. Estimation of Residual Nitrogen in Blood Serum 
as an Index of Hepatic Function. Chauffard Brodin 
Test 24 

The quantity of residual nitrogen in blood serum is 
obtained by subtracting the urea nitrogen from the 
total nitrogen estimated in dealbuminized serum. Re- 
sidual nitrogen is made up of ammonia, amino-acid, 
uric acid, etc. It has been contended that the elabora- 
tion of residual nitrogen products is exclusively de- 
pendent upon the liver. In normal persons the re- 
sidual nitrogen is always below 10 grams per liter 
of serum. In many acute and chronic diseases of 
the liver, the residual nitrogen has been found above 
10 grams, the amount being in proportion to the grav- 
ity of the hepatic lesion. The diet and condition of 
the kidney are negligible. 

The estimation of the amount of residual or rest 
nitrogen in the blood serum has come to be regarded 
as of more importance as a test of kidney than of liver 
function. For this reason a more complete account of 
the method and its interpretation will be found later 
under that head. 

General Summary of the Value of Ureagenetic Func- 
tion Tests. — In the first place it must be admitted that 
some of these ureagenetic tests are complicated to such 
an extent that they cannot be carried out without the 
assistance of an expert chemist, thus diminishing their 
applicability to clinical work. 

Further than this it must likewise be admitted that 
many physiological causes of error exist which militate 
against a too strict interpretation of results. Other 
factors besides the liver collaborate in nitrogen metab- 

24 Jour. Biol. Chem., 1912, XII, p. 301; Jour. Amer. Chem. Soc, 
1913, XXV, p. 1567. 



Tests of Liver Function 41 

olism. 

Notwithstanding these valid objections it must be 
admitted that the study of nitrogen has given some 
useful results and it is to be hoped that future investi- 
gations may bring a greater degree of order from the 
now more or less confused and contradictory material 
which comprises our stock of knowledge today concern- 
ing the true relation of the liver to nitrogenous metab- 
olism. 

When this day arrives the clinician will be better 
able to interpret the results obtained from ureagenetic 
tests than he is at the present time. 

III. FUNCTIONAL TESTS TO DETERMINE DISTURBANCE 
OF THE ANTITOXIC FUNCTION OF THE LIVER 

Poisons which obtain access to the organism through 
the portal circulation are fixed and destroyed under 
normal circumstances by the liver cells. It is natural, 
therefore, that this important function should be em- 
ployed as a basis for testing the integrity of the organ. 

The first efforts made in this direction consisted 
in estimating the toxicity of urine and blood serum. 
An increase of toxicity of these bodies, it was held, in- 
dicates diminished toxicopexic power of the liver paren- 
chyma. Tests of this character are carried out upon 
lower animals. The urine to be tested being injected 
intravenously into rabbits according to Bouchard's 25 
method, and blood serum or urine into the cerebrum 
of rabbits according to Widal's method. The numerous 
sources of error and the technical complications sur- 
rounding these two methods have prevented their intro- 
duction into clinical medicine and they need not be 

25 See also Estimation of Urinary Toxicity as a Test of Renal 
Function. 



42 Manual of Vital Function Testing Methods 

described. 

The methods which are in use to determine the anti- 
toxic functional power of the liver are two in number. 
They are as follows: 1. The Methylene Blue Test of 
Chauffard and Castaigne. 2. Estimation of Indica- 
nuria, Spontaneous and Provocative. 

1 . Methylene Blue Test of Toxopexic Function of the 
Liver. Chauffard, Castaigne Test 26 

When the liver cell is unable to properly arrest and 
fix poisons, it reacts to the passage of methylene blue 
through its parenchyma by an intermittent elimina- 
tion. 

Test. — Inject 1 c.c. of 5% solution of methylene 
blue subcutaneously. Collect and examine the urine 
in half an hour, then every hour. Normally at the 
end of half an hour after injection the urine becomes 
colored, the color rising to maximum in 3 or 4 hours, 
disappearing in about 50 hours. If the elimination 
when it commences instead of being continuous occurs 
in cycles, that is intermittently, the test is positive and 
may indicate hepatic insufficiency. 

It must be acknowledged that the value of this test 
is greatly diminished by the fact that the state of 
renal permeability must be considered, since this will 
have a predominant influence upon the quantity and 
rapidity of elimination. Where this factor is known 
the test may be of value. 

Rochets Modification of Chauffard's Methylene Blue 
Test.- — In this test the methylene blue is taken inter- 
nally instead of being given hypodermically. .002 gm. 

^Presse Med., 1898, April 23; Jour, de Physiol. Path., 1899, 
May. See also Babaliantz, These de Geneve, 1919. 



Tests of Liver Function 43 

of methylene blue is swallowed at eight o'clock in the 
morning on an empty stomach. The substance is given 
in capsule. The urine is collected every four hours in 
separate vessels. If the urine of the second recipient 
is clearly colored it will denote inability of the liver 
to retain the pigment and consequent hepatic insuf- 
ficiency. Normally this amount of methylene blue 
should be completely arrested and fixed by the liver 
so that no coloring matter appears in the urine after 
its administration. If the test is positive, the urine, 
especially that passed four to eight hours after ad- 
ministration, will be colored green. 

Unfortunately the condition of the kidney must also 
be reckoned with in applying this test, as failure of 
elimination of the dye may be due to renal impermea- 
bility. 

The same remarks with respect to renal permea- 
bility apply in interpreting the Roche modification as 
when the dye is given by hypodermic injection. It 
can never be known a priori whether a failure of elimi- 
nation is due to renal insufficiency or to normal fixa- 
tion of the dye by the liver cell. In other words, the 
state of the kidney function must be previously known 
or ascertained. 

2. Indicanuria Spontaneous and Provocative as a 
Means of Testing the Integrity of Hepatic Fixa- 
tion 

Spontaneous Indicanuria. — It has been urged that 
the normal liver is always capable of arresting and 
destroying indican which is formed in the intestine as 
a result of putrefaction of albuminoids. Therefore 
the spontaneous presence of indican in the urine has 
been held to be evidence of hepatic insufficiency. 



44 Manual of Vital Function Testing Methods 

Provocative Indicanuria — .001 gm. of indol is in- 
gested in the morning on an empty stomach. The urine 
is collected every four hours and examined for indican. 
The individual to be tested should be put on a milk 
diet for a few days before the substance is ingested. 

Tests for Indican in the Urine. — Qualitative. — The 
principle involved is to decompose the sodium or po- 
tassium compound of indoxyl sulphuric acid present in 
the urine by strong HC1 and oxidizing this compound. 

Obermayer's reagent is usually employed. This con- 
sists of strong HC1, sp. gr. 1.19, to which is added two 
parts per thousand of ferric chloride. The liquid is 
fuming yellow and keeps indefinitely. 

Precipitate the specimen of urine to be tested with 
a small amount of lead acetate or subacetate, avoiding 
excess, and filter. This removes pigments. 15 c.c. of 
filtered urine are mixed with equal quantity of Ober- 
mayer's reagent and 2 c.c. of chloroform added. Cork 
or cap the tube with rubber, and slowly invert. The 
chloroform takes on a blue color whose depth will 
roughly show the amount of indican present. 

Quantitative. — Strauss' 27 method is a good one. 
Twenty c.c. of urine are mixed with 5 c.c. of 20% lead 
acetate solution and filtered. Ten c.c. of filtrate (cor- 
responding to 8 c.c. urine) are placed in a small gradu- 
ated separatory funnel and mixed with 10 c.c. of Ober- 
mayer's reagent (v. s.). 

Five c.c. of chloroform are added, the tube corked 
and gently shaken. This is repeated in two minutes. 
Pour the chloroform from the tube. Add 5 c.c. of 
chloroform and repeat the extraction. Continue until 
added chloroform remains colorless. 

"Deutsch. med. Wchnsch., 1902, p. 299. 



Tests of Liver Function 45 

Two c.c. of united chloroform extracts are put in 
a small test tube of same diameter as tube containing 
standard solution. Chloroform is added drop by drop 
until colors are matched, against white background. 

The standard solution is made by dissolving .001 gm. 
C.P. indigotin (Kahlbaum) in 1000 c.c. of chloroform. 
Portion is sealed in test tube and kept in the dark. 

If the total amount of chloroform used for extrac- 
tion is equal to a and the amount of chloroform used 
to dilute the 2 c.c. to the color of the standard tube 
equals x, the total amount of chloroform necessary to 
dilute all the chloroform used in extraction equals 

The total number of c.c. used in the extraction and 
in the dilution of the extraction mixture represents, 
therefore, a bulk containing .001 gm. of indigo. 

In normal urines 5-10 c.c. of chloroform are usually 
all that is required to extract the whole amount. 

To obtain the results in milligrams it must be con- 
sidered that the amount of indigo extracted was from 
8 c.c. of urine. 



iv. sulpho-conjugation, provocative as a means 
of testing the hepatic function ( foster and 
kahn) 

Assuming that the toxic aromatic radicles as indol, 
skatol, phenol, etc., are normally conjugated in the 
liver with sulphuric and glycuronic acids, with the 
formation of ethereal sulphates, and their elimination in 
the urine,* Foster and Kahn have proposed the fol- 
lowing method for the estimation of hepatic function: 

* Foster and Kahn, J. Lab. and Clin. M., St. Louis, 1916, 11, 1. 



46 Manual of Vital Function Testing Methods 

1. The Sulpho-Conjugation 

"This has helped us much in determination of liver 
function. We shall discuss this in detail. 

"The toxic aromatic radicles produced by decom- 
position of protein are conjugated in the liver with 
sulphuric or glycuronic acid, and are then excreted in 
the urine. If we should take indol as an example, the 
following process would take place : 

"Tryptophane, or beta-indol-alpha-amino-propionic 
acid is one of the products of decomposition and putre- 
faction of proteins. It is the mother substance of 
indol and skatol, etc. Upon breaking down of trypto- 
phane, indol, which is very toxic, is produced. 




C«CH 2 -CH (BH 2 )-C00H 
CH 



(Tryptophane) 




CH 




CH 



NH 

(Indole) 



Tests of Liver Function 



47 



Indol is oxidized in the intestines to indoxyl. 




C - H 



C H 



N H 
( Indoxyl ) 



If indol or indoxyl enters the general circulation 
marked toxinemia results with its concomitant symp- 
toms. The protective mechanism of the body against 
this toxinemia is to conjugate the indoxyl with sulphuric 
acid in the liver, producing a substance which is al- 
most nontoxic — indican. 




(Indoxyl) 



48 Manual of Vital Function Testing Methods 





C - 0- - SO3H 



C H 



N 
H 



(indoxyl sulphuric acid) 
In the presence of potassium salts : 



C - - S0 3 K 





N 

H 



- C H 



(indican) 



(CI 



'Similar results are obtained with any of the aro- 
matic radicles, as phenol, cresol, tyrosin, skatol, etc. 
"It is well known that the total sulphur in the urine 
may be partitioned into three distinct fractions: 

a. The Inorganic Sulphates. 

b. The Ethereal Sulphates. 

c. The Neutral Sulphur. 

"It has been definitely established that, normally, the 
inorganic sulphates form about 70 per cent, of the total 
sulphur, and the remaining 30 per cent, are divided al- 
most equally between the ethereal sulphates and the 
neutral sulphur. 

The ethereal sulphates are the conjugated aromatic 



Tests of Liver Function 



49 



sulphonic acids. It is this fraction that is of special 
interest to us now. 

It is, of course, impossible to rely upon the exertion 
of ethereal sulphates as a symptom of hepatic function. 
The proteins which are ingested daily give rise to their 
quota of aromatic radicals which influence the quantity 
of the conjugated sulphates. The condition of the in- 
testinal flora plays a role in the formation of aromatic 
radicles, thus it is known that in intestinal putrefac- 
tion there is a marked increase in the conjugated sul- 
phates excreted. 

"We, therefore, adopted the following technic for the 
determination of liver function by means of the ethereal 
sulphate output: 

"The patient received a dose of castor oil to clean out 
his bowels. He was then kept on a known diet for two 
days, during which time the urine was collected, pre- 
served, and analyzed for total sulphur and ethereal sul- 
phates.* On the third day the patient received a cap- 
sule containing one-half gram of thymol. The urine 
was collected for the next two days, preserved, and 
analyzed for total sulphur and ethereal sulphates. 

"Thymol is iso-propyl-meta-cresol: 




H 



C E* - C H - C H. 



* The total sulphur was analyzed by Benedict's method; the Ethe- 
real sulphates by Folin's method. 



50 Manual of Vital Function Testing Methods 

"If all the thymol were absorbed and if all the thymol 
were conjugated with sulphuric acid and none with gly- 
curonic acid, the 0.5 gram of thymol would be excreted 
as 0.7666 gm. of thymol sulphuric acid. This would 
cause a marked increase in the percentage of ethereal 
sulphates. If the liver were not functionating properly, 
the thymol would not be conjugated, and the percent- 
age of ethereal sulphates would be only slightly dif- 
ferent from what it had been on the first two days. 

"One objection to the study of the function of any or- 
gan as an index of disease of that organ is, that it is 
perhaps possible for the healthy part of the diseased 
organ to compensate and assume the work of the whole 
gland. In such a condition of course the functional 
output of the organ may be normal, and would be no 
index of the pathological anatomy of the organ. Un- 
der these circumstances only marked destructive 
changes would leave their impress on the functional 
activity of the organ. 

Ethereal Sulphate Elimination Before and After Thymol Administration. 



Case 
No. 



Diagnosis 



Total Sulphur 
gms. 



Before 
Thymol 



After 
Thymol 



Ethereal Sulphate 
Sulphur gms. 



Before 
Thymol. 



After 
Thymol. 



Ethereal Sulphate Sul- 
phur % of Total 
Sulphur. 



Before 
Thymol. 



After 
Thymol. 



1 
2 
3 
4 

h\ 

n\ 

8, 



Normal % T2 
Gastritis] Rl 
Fracture! "\2 
Congestion" of ? 
liver yg^JfO 

Gall-stones ~ r 2 
" " *WW3 
Cholecystitis" 2 
[ 9 jl Atrophic am 
ri| ^cirrhosis'' ^ 2 
10] r F.Tumor7of?.liver?l , 
11 11 Cancerfof Jliverl2 , 
12 Syphilis of J %*■ 
I** liverjjj.,H r 2 



0375 


2.1295 


0.2893 


0.5646 


14.2 


26.8 


9428 


1.7427 


0.1457 


0.3380 


7.5 


19.4 


7467 


2.5527 


0.3131 


0.6024 


11.4 


23.6 


9852 


1.0734 


0.1753 


0.7069 


17.8 


128.6 


7345 


1.6982 


0.2480 


0.3610 


14.3 


121.2 


7628 


2.8075 


0.7597 


1.0303 


27.5 


?36.7 


0042 


2.6826 


0.3965 


0.8474 


13.2 


29.4 


7807 


2.6437 


0.4866 


0.7428 


17.5 


28.1 


2328 


2.3029 


0.2791 


0.3400 


12.5 


15.2 


9492 


1.8757 


0.1637 


0.3676 


8.4 


f 19.6 


7526 


2.6278 


0.6083 


0.6648 


22.1 


25.3 


S2* VP 

8104 I 2.90751$ 0.3990J 


[0.5437 


14.2 


18.7 



Tests of Liver Function 51 



a- 



It has been our experience, however, that disturb- 
ances in the structure of the liver go hand in hand 
with disturbances of function, especially as is indicated 
by sulphuric acid conjugation of the aromatic radi- 
cles. We have found that in cirrhosis of the liver the 
conjugation of thymol with sulphuric acid does not take 
place to as marked an extent as in the normal state. 
This question is now being more fully investigated, and 
in the very near future we hope to make a more exten- 
sive report. Meanwhile, we have cited a few cases 
above. 

"It will be observed that in the nonhepatic diseases, 
and in the non destructive diseases of the liver, a 
marked increase in the excretion of ethereal sulphates 
was observed on the day after the thymol administra- 
tion. In diseases of the liver, like atrophic cirrhosis, 
cancer of the liver, or syphilis of liver, this organ has 
lost its power to conjugate the thymol with sulphuric 
acid. Case number 10 was a benign tumor of the liver, 
and it seems no destructive changes went on in the he- 
patic tissue. This case was in the service of Dr. E. B. 
Haworth. 

"We hope to study this reaction more fully in ex- 
perimental hepatisis, if possible." 

V. FUNCTIONAL TESTS TO DETERMINE DISTURBANCES 
OF THE SANGUINOPOIETIC FUNCTION OF THE LIVER 
CELL 

Some results of practical value have already come 
from tests of hepatic function based upon the hsemic 
activities of the liver. The whole question of the rela- 
tion of the liver to the biology of the blood is very com- 
plex and not completely understood at the present 
time; but it is generally agreed that the liver is inti- 



52 Manual of Vital Function Testing Methods 

mately concerned in the elaboration of some of the 
constituents of the blood, particularly fibrinogen and 
certain of the ferments. 

The hsemic tests so far proposed have dealt with 
two physiological aspects of the relation between the 
liver and blood: first coagulability and second the 
presence of miscellaneous ferments. If the liver is in 
reality the principal source for the elaboration of 
fibrinogen any notable diminution of this substance 
in the blood will indicate a diminution of the func- 
tional integrity of the liver cells. With diminished 
fibrinogen and perhaps also fibrin ferment, a delay or 
deficiency in the coagulability of the blood will ensue. 

One test of liver function will therefore consist in 
estimating the coagulability of the blood. 

With respect to the tests for ferments in the blood 
it may be said that the estimation of lipase is so far 
the most important. The liver under normal circum- 
stances inhibits the formation of this ferment so that 
hepatic insufficiency results in an actual increase in 
the amount of lypolytic enzyme in the blood. 

The other ferment tests of hepatic function are ap- 
parently too subtle and uncertain to be of any con- 
siderable practical value. 

The functional tests which are in use at the present 
day to determine the sanguinopoietic capacity of the 
liver are as follows: 1. Estimation of blood coagula- 
tion time, and estimation of fibrinogen. 2. Estimation 
of fibrinolysis time. 3. Estimation of the amount of 
lipase in the blood. 

1. Estimation of Blood Coagulation Time as an Index 

of Liver Function 

Prolongation of coagulation time of the blood is 
said to be present when the liver is physiologically de- 



Tests of Liver Function 53 

fective and consequently the estimation of coagulation 
time has been proposed as a simple and effective means 
of determining hepatic insufficiency. 

Unfortunately while the relation of normal hepatic 
function to normal coagulation of the blood is un- 
doubtedly intimate and important, it is also true that 
so many other factors besides the liver enter into the 
physiology of blood coagulation as to materially lessen 
its importance as a basis for functional estimation. 

Coagulation time of the blood has also been sug- 
gested by Tettinger and Bachrach as a means of test- 
ing renal function. 

Wright's Method of Estimating Coagulation Time. 
— The necessary apparatus consists of a series of cap- 
illary tubes, elastic bands, a beaker, a jug of hot and 
a jug of cold water, a watch with a second hand and 
a thermometer. The capillary tubes are of the same 
caliber and are provided with a 5 c. mm. mark. The 
procedure is as follows: Clean the patient's thumb 
with ether. Wrap a piece of elastic tubing round the 
thumb from the base nearly to the tip. Puncture the 
tip of the thumb with a sterile surgical needle. Draw 
up blood to the mark on the pipette. It is not essential 
to obtain the exact quantity of blood, slight variations 
in the amount being of less importance than rapid 
manipulation. Note the exact time by the watch. 
Stretch a flat elastic band over the ends of the tube to 
prevent entrance of water. Stand the tube in the 
beaker filled with water at 37° C. Stir the water oc- 
casionally with the thermometer and keep the tem- 
perature constant by adding hot or cold water. 

Prepare three or four more capillary tubes in the 
same way, numbering each tube and taking the time of 
each. At the end of three minutes take out the first 
tube and blow out the blood. Give the second tube 



54 Manual of Vital Function Testvng Methods 

31/2 minutes and if the blood is still fluid give the third 
tube four minutes and so on. The tube from which 
the blood fails to be expelled by blowing gives the co- 
agulation time. The normal time for blood coagulation 
is &Y2 minutes. 

The Fibrinogen Test. Whipple, Hormtz. 2 * — 20 c.c. 
of oxalated blood plasma are heated to 59° C. for 20 
minutes. Fibrinogen is precipitated. The precipitate 
is isolated by centrifugation, washed with water, alcohol 
and ether, dried at 120° C. and weighed. A rough esti- 
mate of the amount of fibrinogen in the blood is made 
by clotting a little plasma with calcium, testing the 
toughness of the clot with a glass rod. The quantita- 
tive or weighing method is, however, better. 

Normally fibrinogen exists in the plasma in the pro- 
portion of .30 to .40 gm. per 100 c.c. In case of liver 
deterioration, alteration or injury the amount will 
be found diminished. In some cases of cirrhosis the fibri- 
nogen content has been found very low (.05 gm. or less). 

#. Estimation of Fibrinolysis Time as an Index of 
Hepatic Function. Goodpasture Test 29 

Very recently, Goodpasture has called attention to 
the interesting and important fact that in chronic, 
atrophic, hepatic cirrhosis the blood possesses the power 
of completely digesting the clot in a few hours at body 
temperature. 

The clot in normal blood remains undigested for 
days and sometimes even for weeks. Goodpasture be- 
lieves that the dissolution of the clot is due to an 

38 Jour. Exp. Med., 1911, XIII, p. 136; also Johns Hopk. Hosp. 
Bull., 1913, XXIV, p. 207, 343. 
29 Johns Hopk. Hosp. Bull., 1914, XXV, p. 330. 



Tests of Liver Function 55 

enzyme. The activity of this enzyme is destroyed by 
heat and inhibited by normal serum. The fibrinogen 
content of the blood in his reported cases (four in 
number) was below normal. He suggests premature 
digestion of clot durante vivo may account for the 
frequency of spontaneous hemorrhage in atrophic 
cirrhosis. The Goodpasture test will, in all likelihood, 
be found of great value in estimating hepatic insuf- 
ficiency in chronic cirrhosis. It will be interesting to 
observe what the test for fibrinolysis will show in early 
or latent cases of cirrhosis as well as in hepatic con- 
ditions generally. 

Technic of Goodpasture Test. — Blood is drawn from 
an arm vein by means of the usual technic. The coagu- 
lation time is estimated.* A portion of blood is drawn 
into 1% solution of sodium oxalate to prevent clotting 
of the specimen. This last is centrifuged and 20 c.c. 
of supernatant plasma is used to determine fibrinogen 
content if this is desired. Otherwise the entire oxalated 
plasma is used for tests of coagulation time and fibrin- 
olysis. 

In testing the oxalated plasma for coagulation time, 
use 1 cc. of plasma -f~ 1 gtt. CaCl 2 (1%). 

The original clot from the drawn blood and speci- 
mens of clotted oxalate plasma are placed in the ther- 
mostat at 37°. They are examined every hour. If the 
test is positive, the blood clot liquefies and is dissolved 
in 3% to 5 hours. 

In negative (normal) cases there is no digestion of 
the clot for several days, even where no aseptic pre- 
cautions are taken. 

* For other methods than Wright's consult modern laboratory 
manuals. 



56 Manual of Vital Functions Testing Methods 

3. Estimation of Blood Lipase as an Index of Liver 
Function. Whipple 9 s Test 30 

There exists normally in the blood a lipolytic fer- 
ment lipase. The percentage of lipase in normal blood 
is remarkably uniform. In certain diseases of the liver 
this ferment has been found to increase in amount indi- 
cating that under normal circumstances the liver in- 
hibits its formation. Any considerable increase, there- 
fore, of lipase in the blood has been held to indicate 
hepatic insufficiency. Whipple, in collaboration with 
Mason and Peightal, found that after acute injury of 
the liver from chloroform there was always found an in- 
crease in the lipase of serum or plasma. Sometimes this 
rise amounted to 1—2 c.c. of 1 / 10 normal acid. Inas- 
much as the content of lipase may increase five to eight 
times the normal under certain conditions of hepatic 
disease it was naturally suggested as a test of hepatic 
insufficiency. 

The value of the test is chiefly qualitative rather than 
quantitative. It has been found of especially positive 
value in suspected eclampsia, chloroform poisoning, yel- 
low atrophy and cholangitis. In cirrhosis of the liver 
there may be a subnormal lipase. 

Tests for Lipase in the Blood. Lowenharfs 31 
Method of Estimating Lipase Is Usually Employed. — 
Blood serum is collected in four tubes and a little 
toluene, .3 c.c, is added to prevent microbic contami- 
nation. Each tube contains 1 c.c. plasma or serum 
diluted with 4 c.c. of distilled water. 

Two of these tubes are used as controls. To the 
others a little ethyl butyrate (butyric ether), .26 c.c, 

80 Johns Hopk. Hosp. Bull., 1913, XXIV, p. 207; ibid., 343; 
ibid., 357. 
81 Amer. Jour. Physiol., 1902, VI, p. 331. 



Tests of Liver Function 57 

is added. The four tubes are shaken, corked and put in 
the thermostat at 38° for 18 to 24 hours. 

At the end of this time the two control tubes are ex- 
amined for their normal alkalinity by means of deci- 
normal acid solution. The other two tubes are titrated 
for free butyric acid by decinormal alkali solution. 

The total lipolytic activity is measured by adding 
the two figures, since the butyric acid formed had to 
first neutralize the normal alkalinity of the serum. 

The exact method is as follows : After incubation 
the tubes are cooled in ice water, 3 drops of azolitmin 
added and then titrated in pairs to a neutral reaction, 
using 1 / 10 normal acid and alkali. The two control 
tubes usually show the blood alkalinity to be 
.1 c.c. 1 / 10 normal acid and the butyrate tubes show 
the acid production to be .1 to .2 c.c. above the neutral 
point. This means that the total lipolytic activity is 
.2 to .3 c.c. 1 / 10 normal solution, that the plasma 
lipase has split up the ethyl butyrate to this amount. 
Normal plasma lipase is then in terms of 1 / 10 normal 
acid equal to .20 to .30 c.c. 

GhedinVs Test. 32 — This consists in an estimation of 
the power of the blood serum to convert glycogen into 
glucose. A reducing ferment supposed to be formed 
by the liver cells effects the conversion. 

The Test. — Blood serum to be examined is added to 
a solution of glycogen. Serum from a known normal 
person is similarly treated and used as a control. 

To both tubes is added a little sodium hydroxide, 
then potassium sulphocyanide, and the solutions fil- 
tered and examined with the polariscope. 

If there is hepatic insufficiency the rotatory power 
of the serum will be less than the normal control. 

32 Gazz. degli ospedali, Milan, Jan. 12. 



58 Manual of Vital Function Testing Methods 

The factors upon which this test are founded are 
rather subtle and imperfectly understood; indeed it is 
by no means accepted that the liver is the unique or 
even the most important source of the ferment which 
affects the conversion of glycogen into glucose. 

^. Application of Abderhalden's 33 Method to Estima- 
tion of Sanguinopoietic Functions of the Liver 

Recently it has been held that destruction of liver 
parenchyma by disease (autolysis) gives rise to the 
presence of an excess of proteolytic ferments in the 
blood serum and this fact has formed a basis for test- 
ing the functional capacity of the liver. 

The technic of the method is too complicated to 
admit of its use in clinical practice and the results ob- 
tained are as yet too meagre to justify any conclusions 
as to its value. 

V. FUNCTIONAL TESTS TO DETERMINE DISTURBANCE OF 
THE EXOCRINOUS OR BILIARY FUNCTION OF THE 
LIVER 

Bile is partly a secretion and party an excretion, for 
it not only plays a role in certain digestive processes, 
notably the splitting or absorption of fats, but it also 
contains certain waste products which escape in the 
feces. It is important to remember, however, that cer- 
tain constituents secreted and excreted in the bile are 
reabsorbed by the intestine and carried back by the 
blood stream to the liver. 

Perfectly fresh hepatic bile, in contradistinction to 
bile in the gall bladder, contains one pigment only, 
namely, bilirubin, and from this pigment others are 

M See Breitmann, Zentrbl. f. innere Med., XXIV, 1913, p. 857. 



Tests of Liver Function 59 

gradually formed by processes of oxidation. Fresh 
human bile from the hepatic duct is golden yellow in 
color but becomes olive brown to grass green after re- 
maining in the gall bladder and cystic duct, because of 
the presence of biliverdin, which is an oxidation product 
of bilirubin. 

It is now universally accepted that the bile pigment 
bilirubin originates from the disintegrated hemoglobin 
of the red blood corpuscles. When these break up 
their contained pigment is carried to and fixed by the 
liver, where it is converted into an iron-free pigment, 
bilirubin. 

It appears that the power of transforming blood 
pigment into bilirubin is not exclusively the property 
of the liver cell, since in old blood extravasions any- 
where in the body a substance, hsematoidin, is found 
which is chemically identical with bilirubin. Under 
ordinary physiological conditions, however, the liver 
seems to be the only place in the body where bilirubin 
is formed. It is not known whether the actual dis- 
integration of red corpuscles is confined to the liver, 
but certainly this organ has the unique power of fixing 
the hemoglobin set free by haemolysis, retaining its 
iron and converting it into bilirubin. 

Under normal conditions bilirubin does not appear 
in the feces, but in its place is found a reduction prod- 
uct which is known as urobilin (stercobilin). The reduc- 
tion of bilirubin to urobilin takes place in the intestine 
from nascent hydrogen liberated by bacterial action. 
Part of this urobilin formed in the intestine escapes in 
the stools. Another portion is reabsorbed by the in- 
testinal mucosa as a protochrome, — urobilinogen. Part 
of this substance is eliminated in the feces. The re- 
mainder passes back through the portal circulation to 
the liver, where it is changed back into bilirubin to be 



60 Manual of Vital Function Testing Methods 

again reexcreted by the bile when the cycle is re- 
peated. 

A very minute amount of the urobilinogen absorbed 
by the bowel escapes in the urine. Under normal con- 
ditions this quantity is very small. 

Soon after urobilinogen is eliminated by the urine, 
it changes to urobilin so that the urobilin is not present 
in freshly passed urine but only appears from the break- 
ing down of urobilinogen by light and air. 

Urobilin was recognized as a constitutent of patho- 
logical urines long before urobilinogen, from which it 
is formed by oxidation, was discovered. 

Urobilinuria and urobilinogenuria may therefore be 
regarded as practically identical and due to the same 
substance in different forms. The pathological causes 
of both are the same. 

It has been known for a long time, however, that 
urobilin appears in the urine in a comparatively large 
number of pathological conditions, among which may 
be mentioned the infectious diseases, particularly ma- 
laria and pneumonia, cirrhosis of the liver, lead poison- 
ing, decompensated heart disease, pernicious anaemia, 
pulmonary infarction and visceral hemorrhages. Like- 
wise certain drugs and poisons are known to produce 
urobilinuria. In obstructive jaundice, it often appears 
in the urine before bilirubin and may, in fact, alternate 
with this substance. Urines which contain much uro- 
bilin present a dark yellow color which may be imparted 
to the foam on shaking. They are thus quite like or- 
dinary icteric urines. 

The hepatic conditions in which urobilin appears in 
the urine fall into two groups: 1. Mechanical inter- 
ference with biliary flow in the ducts. 2. Insufficiency 
of the liver cell. In the first group, if the obstruction 
is absolute as in some cases of stone, no bile reaches 



Tests of Liver Function 61 

the intestine and no urobilin is formed, hence no uro- 
bilinogen appears in the blood or urine. If the ob- 
struction remains complete the bile pigment bilirubin 
begins to be absorbed by the blood and excreted in 
the urine. If the occlusion of the ducts is only partial, 
some bile reaches the intestine, urobilin is formed, ab- 
sorbed and may appear as urobilinogen in the urine. 
On removal of the obstruction the full flow of bile in 
the intestine is resumed. The functional activity of 
the liver is sufficient to eliminate the urobilinogen 
brought to it by the blood from the intestine and hence 
there is no call for its elimination by the kidney and 
it becomes reduced to a mere trace in the urine or com- 
pletely disappears therefrom. 

As a sign of liver insufficiency urobilinogenuria may 
be absolute or relative. Absolute when the liver paren- 
chyma is totally unable to eliminate urobilinogen and 
allows it to get into the blood; relative when an ex- 
cessive breaking down of red corpuscles anywhere in 
the body overwhelms the liver with pigment which the 
cells are unable completely to convert into bilirubin. 
In other words, if the liver is insufficient it will be un- 
able to excrete increased amounts of urobilinogen 
whether derived from intestinal urobilin or from blood 
pigments. In either case there will be an increase or 
accumulation of urobilinogen in the blood and it will 
appear in measurable amounts in the urine. 

Icterus with the appearance in the urine of normal 
bile pigment (bilirubin) may be regarded as a further 
step in such a pathological process. Here the defect 
of excretory function of the liver is greater because 
of actual inflammatory obstruction of the biliary tract. 
Jaundice, as is well known, is the result of the absorp- 
tion into the blood of the bile pigment bilirubin. Jaun- 
dice, whether obstructive or toxemic, is always due to 



62 Manual of Vital Function Testing Methods 

some lesion of the biliary excretory passages by which 
the flow of bile into the intestine is diminished or pre- 
vented and is always accompanied by some inflam- 
matory state of the biliary tubules. Icterus, when 
well marked, becomes clinically quite evident from the 
discoloration of tissue which results. The demonstra- 
tion of bilirubin in, the urine is then superfluous. In 
such an event, icterus becomes an element in the semi- 
ology of hepatic disease and has to be evaluated with 
other symptoms in making a diagnosis. 

The presence of small quantities of bile pigment 
(bilirubin) in the urine is, however, an earlier sign of 
exocrinous hepatic insufficiency than icterus. For this 
reason the tests for bile pigment in the urine become 
tests to a certain extent at least of hepatic disease and 
perhaps insufficiency. 

To summarize the above facts in their relation to 
the estimation of the external secretory function of 
the liver it may be said that disturbances of this func- 
tion are identified by tests which disclose the presence 
in the urine of the three substances above mentioned, 
namely, urobilinogen, urobilin and bilirubin; the tests 
for these substances will therefore be given together 
with special data bearing upon their individual sig- 
nificance. 

There is, however, another way by which the total 
power of the liver to carry on its external secretory 
function may be judged. This consists theoretically, 
in finding a substance which if injected into the circula- 
tion will be eliminated exclusively by the liver. It 
was only in recent years that such a substance was dis- 
covered, phenoltetrachlorphthalein. 

Tests to determine the status of the excretory func- 
tional power of the liver may, therefore, be properly 
divided into two categories : 



Tests of Liver Function 63 

1. Tests for urobilinogen, urobilin and bilirubin in 
the urine with the interpretation of results in reference 
to hepatic insufficiency. 2. Tests to determine the 
global capacity of the liver to eliminate foreign sub- 
stances. In this category there is but one test so far 
devised, namely that of phenoltetrachlorphthalein. 

1. Tests for Urobilinogen, Urobilm and Bilirubin 
in the Urine. Interpretation of Results with Refer- 
ence to Hepatic Insufficiency 

The Urobilinogen Test. EhrlicWs Test. 34 — The Ben- 
zaldehyde Reaction. — While investigating the aniline 
dyes for their effects upon trypanosomes, Ehrlich found 
that the addition of paradimethylamidobenzaldehyde to 
certain fresh urines produced a bright red coloration. 
This was in 1901. In 1903 Pappenheim 35 called atten- 
tion to the fact that the reaction occurred only in those 
urines which, on standing, gave the reaction of urobilin. 
In the same year Neubauer 36 demonstrated that the 
reaction was due to urobilinogen, a colorless chromogen 
which gradually becomes converted into urobilin. 

Technic. — The test is very simple. Add to fresh 
urine in a test tube several drops of Ehrlich's reagent. 
The reagent is as follows: 

Paradimethylaminobenzaldehyde ... 8 gms. 
Concentrated hydrochloric acid .... 80 gms. 
Distilled water 200 gms. 

If urobilinogen is present a red color appears. The 
color reaction in the cold urine is of pathological sig- 

34 Wien. med. Wchnschr., 1901, XV; Munch, med. Wchnschr., 
1901, XV. 
85 Berl. klin. Wchnschr., 1903, II, p. 42. 
36 Sitz. d. Gesell. f . Morph. u. Physiol., Munich, 1903, July, H. ii. 



64 Manual of Vital Function Testing Methods 

nificance only when a distinct scarlet color is obtained. 

There are a few sources of possible error. The in- 
gestion of hexamethylamine or antipyrine may cause 
the same reaction. The presence of acetone in the 
urine must also be excluded as it produces a similar 
coloration. 

If the reaction persists after free purgation it is 
more significant. The reaction is not constant in all 
conditions in which it has been found because the liver 
may be able to excrete enough urobilinogen to prevent 
its appearance in the blood and urine. 

Urobilinogen has been found in the urine in many 
pathological conditions, chief of which are cirrhosis of 
the liver, cholangitis, infectious diseases, heart diseases 
in the stage of decompensation, pernicious anaemia, pul- 
monary infarction and visceral hemorrhage. 

Ehrlich's test has been highly recommended as a clin- 
ical method for determining hepatic insufficiency by 
Miiller, Bauer, Neubauer, Hilderbrand and others. It 
has been regarded by some observers as an adequate and 
infallible criterion of hepatic function. Some observers 
have claimed for it a prognostic significance. All of 
these contentions have been found to overstate the facts. 

The presence of urobilinogen in considerable quan- 
tity in the urine may indicate that there is a partial 
interruption in the biliary excretion and that some of 
the intestinal urobilin absorbed into the blood is not 
being thrown off by the liver. The primary cause may 
be either a disorder of the liver cells or a congestion or 
toxemic obstruction of the biliary channels. 

The discovery of a persistent urobilinogenuria should 
therefore point to a careful study of the hepatic func- 
tions by all known means. If hepatic insufficiency can 
be ruled out the only remaining explanation is that 
excessive destruction of the blood corpuscles is taking 



Tests of Liver Function 65 

place somewhere in the body. 

Recently rather strong criticisms of Ehrlich's test 
have appeared. Wilbur and Addis 37 in 1913 stated 
that thev do not believe it constitutes a reliable criterion 
of hepatic function. This opinion has been reiterated 
by Chesney, Marshall, and Rowntree, 38 last year. All 
these authors maintain that observations on a single 
or 24-hour specimen of urine have no significance. That 
great variations appear from day to day and that 
only when repeated tests are made covering a period of 
two weeks, controlled by studies of urobilin content in 
the feces, can the results be accepted. 

The simplicity of Ehrlich's test will insure for it a 
permanent, if not paramount, place. It must always 
be remembered that only a persistent and well-marked 
urobilinogenuria is to be regarded clinically as sig- 
nificant. 

A well-marked and lasting reaction appears to in- 
dicate one of two things, an hepatic insufficiency or 
excessive hemolysis. There is nothing in the test itself 
to enable a differentiation between the two to be made. 
The test is therefore of some importance when regarded 
only as a corroborative sign of insufficiency of the 
excretory function of the liver. 

Tests for Urobilin. — First add to the urine a few 
d,rops of 10% solution of zinc chloride and enough am- 
monia to dissolve the precipitate. Filter into "a test 
tube and hold same against a dark background ; a green 
fluorescence denotes urobilin. Equal quantities of 1% 
solution of zinc acetate and urine may be used in the 
first part of the test. The fluorescence may be made 
more visible by concentrating light on the tube with a 

n Arch, of Int. Med., 1913, Feb., p. 235. 

38 Jour. Amer. Med. Assn., 1914, LXXIII, p. 1533. 



66 Manual of Vital Function Testmg Methods 

lens. 

Another and perhaps more delicate method of de- 
tecting urobilin is to extract 50 c.c. of urine with 50 c.c. 
of pure ether. Pour off the ether into a tube and evap- 
orate. Dissolve the brown residue in a little strong 
alcohol. The solution will be pale yellow with a green 
fluorescence if urobilin is present. 

A third method is to acidify 20 c.c. of urine with 
several drops of HC1. Shake gently with 5 c.c. of amyl 
alcohol. This extracts the pigment and shows a bright 
green fluorescence when treated with an alcoholic solu- 
tion of zinc chloride and a little ammonia. By trans- 
mitted light the amyl alcohol is a faint pink shade. 

The most rapid method of testing for urobilin is by 
the use of the pocket spectroscope. If the urine is dark 
it should be diluted. The characteristic spectrum band 
is seen between the green and blue, between, the lines 
C and F. 

Tests for Bilirubin. — The tests usually employed are 
those of Gmelin, Rosenbach, Huppert and Smith. 

Gmelin's Test. — The urine is treated with sufficient 
concentrated HN0 3 containing a trace of nitrous acid, 
sufficient to form a layer beneath. If bilirubin is pres- 
ent there will be a play of colors at the zone of contact 
from yellow through green, blue, violet, red and orange. 
The green will lie nearest the urine and the orange in 
the upper acid. 

Rosenbach's Test. — Filter the urine through Swedish 
filter paper ; apply a drop of HN0 3 containing a trace 
of nitrous acid upon the paper. The play of colors 
above mentioned under Gmelin's test will appear. 

Huppert's Test. — Precipitate the urine with barium 
chloride and ammonia. The precipitate is washed with 
water. Wash the precipitate with alcohol into alcohol 



Tests of Liver Function 67 

acidulated with sulphuric acid. Boil for a time. If 
bilirubin is present an emerald green color will appear. 
Smith's Test. — A small amount of urine is placed in 
a test tube and overlaid with a few c.c. of tincture of 
iodine diluted with alcohol 1 :10. If bilirubin is present 
a distinct emerald green ring will develop at the zone of 
contact. 

#. Tests to Determine the Global Capacity of the 
Liver to Eliminate Foreign Substances 

The Phenoltetrachlorphthalein Test of Liver Func- 
tion. Rowntree, Horwitz, and Bloomfield Test. — Phe- 
noltetrachlorphthalein was originally studied pharma- 
cologically by Abel and Rowntree 39 in 1909. It was 
proposed in 1913 as a test for functional capacity of 
the liver by Rowntree, Horwitz, and Bloomfield. (Johns 
Hopk. Hosp. Bull., 1913, XXIV, p. 327.) Important 
experimental work was done on the drug in 1913 to 
determine its behaviour in different liver injuries, by 
Whipple, Mason and Peightal, 40 and by Whipple, 
Peightal and Clark. 41 

Great interest is attached to the phenoltetrachlor- 
phthalein test for liver function; first, because it bids 
fair to become the most satisfactory test for the pur- 
pose yet devised, and, secondly, because all the work 
upon it has been done in America. 

Professors Orndorff and Black 42 of Cornell Univer- 
sity were the first to make the substance in 1909. The 
pharmacological investigations of Abel and Rowntree 
included a study of phenolphthalein together with the 
new synthetic phthaleins, with special reference to their 

18 Jour. Pharmacol, and Exper. Therap., 1909, I, p. 231. 

40 Johns Hopk. Bull., 1913, XXIV, p. 207. 

41 Johns Hopk. Bull., 1913, XXIV, p. 343. 
49 Amer. Chem. Jour., XLI, 1909, p. 349. 



68 Manual of Vital Function Testing Methods 

behaviour as purgatives. They found that phenolphtha- 
lein and its halogen substitution products, of which 
phenoltetrachlorphthalein is one, do not differ greatly 
in their physiological action. They are nonirritant to 
mucous membranes and subcutaneously when injected in 
oil. They are of low toxicity and possess no bacteri- 
cidal action. 

Both phthaleins are laxative when given by mouth, 
subcutaneously or intravenously. When an oily solu- 
tion of phenoltetrachlorphthalein (.4 gm.) is injected 
under the skin of dogs or human beings a laxative action 
is induced which continues from 4 to 6 days. When the 
tetrachlorphthalein is given subcutaneously it escapes 
from the body exclusively in the bile. When the same 
substance is given by mouth it is not absorbed. After 
subcutaneous administration of phenoltetrachlorphtha- 
lein the drug escapes dissolved in the bile and becomes 
later absorbed by the mucous membrane of the large 
intestine. 

These facts form the physiological basis for the phe- 
noltetrachlorphthalein test. The drug is eliminated ex- 
clusively, or practically so, in the bile, and since this 
excretion can be hurried through by purgatives, no time 
will be given for its absorption, and thus the actual 
amount of the drug eliminated may be found. 

The experimental work done by Whipple, Mason and 
Peightal, and by Whipple, Peightal and Clark has 
established the fact that there is a striking parallelism 
in animal observations between the amount of experi- 
mental liver injury produced and the amount of phtha- 
lein eliminated. 

Their method of determining this fact was as follows : 
Female dogs were used because of ease of catheteriza- 
tion. The dogs were given intravenously .1 gm. of the 
phthalein when weighing between 10-20 pounds ; .2 gm. 



Tests of Liver Function 69 

when weighing over 20 pounds. The injection was given 
in the forenoon and 200-300 c.c. of water administered 
by stomach tube. After 5 or 6 hours the urine was col- 
lected and magnesium sulphate and croton oil given to 
produce several semi-fluid stools. The feces were col- 
lected next morning. The total feces were then diluted 
to 1 to 2 liters. The mixture was made alkaline with 
5-10 c.c. of 40% solution of sodium hydroxide and 
shaken until uniform. One tenth of this quantity was 
taken and diluted to 500 c.c. with water, 3 to 4 c.c. of 
40% solution sodium hydroxide added and the mixture 
thoroughly shaken. Of this second solution 100 c.c. 
were precipitated with 5 c.c. of saturated solution of 
basic lead acetate. After a few seconds a curdy pre- 
cipitate fell. The solution was made up to 200 c.c. 
with water containing 4 c.c. of 40% solution sodium 
hydroxide. On standing, the supernatant fluid showed 
a clear phthalein color. This was filtered and the clear 
solution read off in a colorimeter against a standard 
solution .01 gm. phthalein to the liter. 

In the hands of its authors, this method gave pretty 
uniform results ; on normal dogs the amount excreted 
being 35 to 50% with .1 gm. injection and 40 to 50% 
with .2 gm. injection. The drug did not appear in the 
urine. About 10-15% of the phthalein injected was 
lost from the time of the injection to that of its being 
poured out by the bile into the intestine. This shows 
that the liver is quite specifically concerned in the elim- 
ination of the substance, phenoltetrachlorphthalein. 

Whipple and his collaborators found that when the 
liver parenchyma is artificially injured, as by chloro- 
form, phosphorus or hydrazine, there is a very notable 
drop in the output of the substance in the feces down 
to 20 or 10% or even a mere trace. The phthalein then 
begins to be excreted by the urine. When the hepatic 



70 Manual of Vital Function Testing Methods 

lesion improves, the phthalein output in the bile in- 
creases toward normal. The normal output of phe- 
noltetrachlorphthalein in dogs is 45% of the amount 
injected. The drop in phthalein output is always pro- 
portional to the extent of liver injury. If the injury is 
grave enough to produce death, the phthalein output 
falls to zero. In some instances as the effects of the 
hepatic injury are spontaneously repaired, there may 
be an actual increase of phthalein output even above 
normal, a hypersecretion of phthalein as it were. 

Besides injury to the liver parenchyma by poisons, 
the above investigators found that severe circulatory 
disturbances artificially produced are followed by a 
drop in the phthalein output. Actual destruction of 
liver parenchyma produces similar results. 

In experimental obstructive icterus there is, of course, 
no phthalein output, since none of the drug reaches the 
intestine. In experimental hematogenous icterus there 
is no modification of phthalein output. 

The experimental studies so far performed indicate 
that the phenoltetrachlorphthalein will be valuable from 
a quantitative as well as a qualitative standpoint in 
the estimation of insufficiencies of liver function. 

The clinical application of phenoltetrachlorphthalein 
as a test for hepatic function was first worked out by 
Rowntree, Horwitz and Bloomfield. 

We owe to Rowntree the suggestion that the specific- 
ity of the liver in excreting phenoltetrachlorphthalein 
analogous to that of the kidney towards phenolsulphon- 
phthalein would indicate that estimations in man of 
the quantity of dye excreted by the liver after an in- 
travenous injection ought to afford a practical clinical 
method of determining the functional capacity of the 
liver. 

It will thus be seen that the phenoltetrachlorphthalein 



Tests of Liver Function 71 

test of Rowntree, Horwitz and Bloomfield is founded 
upon rational theoretical considerations and that it was 
subjected to a very rigid experimental investigation. 

Technic of Phenoltetrachlorphthalein Test. — An 
aqueous solution of the disodium salt is used. It is pre- 
pared by placing 2.5 gms. of phenoltetrachlorphtha- 
lein in a 200 c.c. Erlenmeyer flask with 5 c.c. of 2 / n 
NaOH solution and 45 c.c. of freshly distilled water. 
This is boiled under a reflux condenser for 20 minutes. 
The solution is filtered into a 100 c.c. flask. This solu- 
tion is of 5% strength and is approximately isotonic 
with blood. It is intensely purplish red in color. Since 
the phthalein is precipitated by C0 2 in the atmosphere 
it will not keep more than a few days, hence requires 
to be freshly prepared for use. The patient is given 
two compound cathartic pills the night before the test 
is applied. 

In making the test 8 c.c. of the solution which will 
contain about 400 milligrams of tetrachlorphthalein are 
measured. It has been found that this amount is never 
followed in normal persons with the excretion of any 
dye in the urine and is sufficient to produce an intense 
color in the final preparation of the feces. The 8 c.c. 
is given intravenously as follows, of course under strict 
aseptic precautions : 

A funnel with properly connected intravenous system 
is filled with freshly distilled water or salt solution and 
the flow into the vein is started. When this is well 
established, the phthalein solution is added. Fifty to 
100 c.c. of water are used and the phthalein solution is 
washed in with freshly distilled water until the fluid 
entering the vein is clear. About a quarter of an hour 
is required for the injection. 

After the injection, the patient is given another pur- 



72 Manual of Vital Function Testing Methods 

gative, usually two compound cathartic pills, and this 
dose is repeated the following morning if the bowels are 
not running freely. The stools are collected for 48 
hours in a covered vessel. The urine is collected for 
24 hours. 

The quantitative determination of the amount of 
phthalein passed is made as follows: The total feces 
collected are put in a wide mouth 2 liter bottle diluted 
with water to 1 or 1.5 liters, according to quantity, 
and the whole put in a shaking machine and well agi- 
tated for from 5 to 20 minutes. 

One-tenth of the total amount is immediately poured 
off in a 1-liter flask. To this is added 5 c.c. of 40% 
NaOH, which makes the mixture a dirty red color. The 
flask is stoppered and thoroughly shaken. One hun- 
dred (100) c.c. of the contents of this flask are placed 
in a 200 c.c. flask, to which is added 5 c.c. of saturated 
basic lead acetate. This decolorizes the mixture and 
throws down a heavy precipitate which leaves a color- 
less supernatant liquid. Five (5) c.c. of 40% solution 
of NaOH are added, which produces the phthalein 
color. More hydroxide solution may perhaps be needed 
to bring out the full color, but excess should not be 
used. The contents of the flask are then made up to 
200 c.c, shaken, and the solution allowed to stand five 
minutes. The supernatant fluid is clear and some can 
be poured off for colorimetric examination. The read- 
ing is made in a colorimeter similar to the one used in 
testing kidney permeability with phenolsulphonphtha- 
lein. The comparison solution is made by taking .4 
c.c. of the original solution used for injection and 
diluting it up to 1 liter plus sufficient NaOH to make 
the deepest color. The per cent, of dye eliminated can 
be read off on the instrument. 

If the reading is low be sure that the maximum color 



Tests of Liver Function 73 

has been developed by adding a little NaOH again to 
the 200 c.c. dilution above mentioned. NaOH must be 
carefully added because excess will tend to render solu- 
tions yellowish red instead of pure purple red. 

In case the quality of color is unsatisfactory the 
authors of the test recommend the following procedure : 
After the addition of about 10 c.c. of 40% NaOH dilute 
the feces mixture up to 1 liter. Take one-tenth of this 
and add 5 c.c. of sodium hydroxide and water up to a 
liter. One hundred c.c. of this is put in a 200 c.c. flask 
and to it is added 5-10 c.c. or more of the following 
solution : 

CaCl 2 90 gms. 

Cone. NH 4 OH 10 c.c. 

Water 50 c.c. 

This brings out a good quality of color. Dilute up to 
200 c.c. and allow to stand covered for some hours, per- 
haps even 24. The supernatant liquid is then tested 
in the colorimeter with the standard solution as above. 
The lower limit of normal output is 30%. 

A year's experience with the phenoltetrachlorphtha- 
lein test of liver function has prompted a recent com- 
munication from Chesney, Marshall, and Rowntree 
(Jour. Amer. Med. Assn., 1914, LXIII, p. 1533) in 
which these authors conclude that outspoken changes in 
the liver can, in most cases, be demonstrated by the test. 
It was found positive in advanced cirrhosis, in passive 
congestion (cardiac liver) and in cancer and syphilis 
involving the liver. 

These authors recommend the association with the 
phthalein test, of estimation of nitrogen partition in 
the blood and urine, and fibrinogen estimation in the 
blood serum. 



74* Manual of Vital Function Testing Methods 

They make the important general observation that 
the information to be derived from tests of the liver 
function does not compare in reliability with that ap- 
plied to the kidney. Similar views have likewise been 
expressed by other writers. The reason would appear 
to be plain. We do not as yet understand the functions 
of the liver regarded as a unit or dissociatively as we 
do those of the kidney. The symptomatology of hepatic 
insufficiency is not understood to an equal extent with 
that of the kidney. However this may be, sufficient 
progress has been made to afford ample congratulations 
for the work of the past and an optimistic outlook for 
future developments. 

Krumbhar 43 has recently stated as a result of his 
researches and investigations that the phenoltetrachlor- 
phthalein test of Rowntree, Horwitz, and Bloomfield 
promises a greater value than all other tests so far 
devised for estimating the functional capacity of the 
liver. 

48 N. Y. Med. Jour., 1914, c. 719. 



CHAPTER II 
TESTS OF KIDNEY FUNCTION 

GENERAL CONSIDERATIONS 

Historical. — In 1830 Hahn noticed after ingestion 
of turpentine in gouty persons that the substance failed 
to render the urine odorous as it was known to do in 
healthy persons. In 1837 Rayer noticed the same 
thing with regard to asparagus. 

Clinicians for a long time have known that many 
persons with nephritis can not take mercury, salicylates, 
iodides, bromides and various other drugs without rap- 
idly showing signs of intolerance. Todd wrote upon 
this subject in 1857 and Roberts in 1865. Duckworth 
and Bouchard in 1873 showed experimentally that 
many drugs which normally pass quite readily through 
the kidney, fail to do so in nephritis. 

The first practical application of these facts was 
made by Achard and Castaigne, who introduced methyl- 
ene blue in 1897 as a direct test of the functional 
capacity of the kidneys. 

Physiological. — As well expressed by Blum the fun- 
damental function of the kidney is its osmoregula- 
tory power; its power to constantly maintain at an 
unvarying point the molecular concentration of the 
blood. This it does by removing a series of substances 
whose accumulation in the organism would eventually 

75 



76 Manual of Vital Function Testing Methods 

produce serious and even fatal consequences. These 
substances are removed in the urine. 

Two general theories of urinary secretion have 
existed, side by side, for several decades. They are 
known eponymically by their originators and although 
they have been added to or subtracted from in details 
by a host of subsequent workers they yet stand as op- 
posing schools of physiological interpretation. These 
schools are known as that of Ludwig on the one hand 
and that of Bowman-Heidenhain on the other. 

According to Ludwig, the elimination of urine is a 
simple process of physical filtration and diffusion. The 
anatomical structure of the glomerulus and the physio* 
logical conditions existing therein, appearing to favor 
the idea of filtration, Ludwig believed that water passes 
through the epithelium of the capillary wall and the 
glomerular epithelium as through a filter, carrying with 
it sodium chloride and other inorganic salts and urea, 
and that the diluted urine in its passage through the 
uriniferous tubules becomes concentrated through loss 
of water by diffusion into the more concentrated blood 
and lymph. 

According to the other theory, that of Bowman- 
Heidenhain, the elimination of urine is fundamentally 
a secretory act and not fundamentally a physical act. 
It assumes that the glomerulus secretes water and inor- 
ganic salts while the epithelial cells of the uriniferous 
tubules secrete urea and the other specific constituents 
of the urine. 

We shall not attempt here either a historical or phys- 
iological review of these theories. It may be said that 
the majority of physiologists adhere to the more con- 
servative and vitalistic hypothesis of Bowman-Heiden- 
hain. The grounds for this belief, and, indeed, all of 
the facts bearing upon both sides of this now classical 



Tests of Kidney Function 77 

controversy, are properly to be found in any modern 
text book of physiology. 1 

It is pretty generally agreed that whether by filtra- 
tion or secretion, water leaves the kidney through the 
glomerulus. Beyond this generally accepted fact there 
is so little unanimity of opinion as to the exact place 
where sodium chloride urea and the other solid constitu- 
ents of the urine are eliminated, that it is impossible to 
make any categorical statement with reference thereto. 
Many attempts have been made to divide up the total 
kidney function into categories or topical functions and 
to locate these functions anatomically in parts of the 
glomerulo-tubal structure. But it cannot be pretended 
at the present time that any such differentiation has 
been proven, certainly not to such an extent as to 
justify deductions of great practical importance. This 
question will, however, be more fully elaborated later. 

The composition of the urine is far from simple. Its 
chief constituents, apparently, are water, sodium chlo- 
ride and urea. But besides these substances, urine con- 
tains purine bodies (uric acid, xanthin, hypoxanthin), 
creatinin, oxalates, glycuronates, phosphates, sul- 
phates, various oxy-nitrogenous and fatty acids, and 
the pigments urochrome and urobilin. 

Nearly all of the nitrogen excreted from the body is 
supposed to pass through the kidney. The total amount 
of nitrogen eliminated in the urine in 24 hours is conse- 
quently regarded as the most important index of proteid 
metabolism. The actual estimate of total urinary nitro- 
gen is usually done by the method of Kjeldahl (described 
under Liver Tests, q. v.). 

The total weight of nitrogen in the urine multiplied 
by 6.25 gives the amount of protein broken down in 
the body, since nitrogen forms 16% of the weight of 
x See Howell, Halliburton, etc. 



78 Manual of Vital Function Testing Methods 

the protein molecule. The total amount of nitrogen 
eliminated in 24 hours by a normal adult is between 
14 and 18 grams, which corresponds to 88-117 grams 
of protein. 

The total nitrogen eliminated in the urine is divided 
as follows: 1. Urea nitrogen; this averages 87.5% of 
the total. 2. Ammonia nitrogen; this averages 4.3% 
of the total. 3. Creatinin nitrogen, 3.6%. 4. Purin 
nitrogen, variable. 

Urea occurs in the urine as its chief nitrogenous 
constituent (about 2% ). Since a normal adult secretes 
1500 to 1700 c.c. of urine in 24 hours the amount of 
urea eliminated will vary from 30 to 34 grams. Urea, 
of course, is not manufactured by the kidneys, but is 
merely eliminated by them. Urea is a normal con- 
stituent of blood existing in that fluid in quantities 
varying from .035 to .153%. If the kidneys are re- 
moved or become impassible to urea this substance 
accumulates in the blood. 

Sodium chloride is the chief inorganic constituent of 
urine, amounting to about 15 grams per day in a nor- 
mal adult. 

Under pathological conditions a variety of sub- 
stances organic and inorganic may appear in the urine, 
whose search and identification is a part of the routine 
analysis conducted for clinical purposes. 

A consideration of these substances belongs, of 
course, to the domain of general clinical pathology. 
The question of how far an ordinary urinary examina- 
tion can serve to reveal the functional capacity of the 
kidney will be taken up presently. 

The kidney functionates normally at a point below 
its maximum capacity, retaining unused a certain 
amount of functional energy which constitutes its re- 
serve. When this reserve becomes exhausted the func- 



Tests of Kidney Function 79 

tional capacity of the organ will be irremediably dam- 
aged unless it can recuperate. When uremia or edema 
have appeared the amount of functional incapacity of 
the kidney has become considerable. No special test of 
function is required to discover it, perhaps, but even 
under such conditions, it may be extremely useful to 
determine just how far, in any given case, the deprecia- 
tion of functional integrity has gone. 

Classification. — There are various general plans by 
which the functional state of the kidney may be in- 
vestigated. 

In the first place we may determine how far the kid- 
ney is able to eliminate increased amounts of its normal 
constituents, such as water, salt and urea. 

In the second place we may select substances foreign 
to the organism, but which are eliminated by the kid- 
ney, and determine the rate and quantity of their excre- 
tion. Iodide of potassium, lactose, phenolsulphon- 
phthalein, phloridzin are examples of such substances. 

Thirdly, the study of the blood will constitute an- 
other avenue of approach to the problem of estimating 
the function of the kidney, because one important result 
of renal insufficiency will be the accumulation of sub- 
stances in the blood which should be eliminated in the 
urine. Among methods of this type may be mentioned 
partitive estimations of nitrogen in the blood, particu- 
larly incoagulable nitrogen. Such examinations will 
often disclose an abnormal degree of accumulation or 
retention of such products in the blood if a condition 
of renal impermeability or insufficiency exists. 

Thus it will be seen that all tests for kidney function 
are based upon the broad principle that any deprecia- 
tion of renal activity will be reflected in the urine on the 
one hand and the blood upon the other. The urine will 
contain less of its normal constituents than normally 



80 Manual of Vital Function Testing Methods 

and less of any substance artificially eliminated by the 
kidney, while the blood will show the effects of renal 
inadequacy by disclosing an accumulation in the plasma 
of substances which are normally excreted continuously 
in adequate amounts. 

All tests for renal function so far devised may be 
satisfactorily divided into the three following cate- 
gories : 

1. The urine as an index of renal function — (a) 
Urinalysis, (b) Physical and Biological characteristics. 
2. The Blood as an index of renal function. 3. Elimi- 
nation of foreign substances by the kidney as an index 
of renal function. 

In the following synopsis, we may see how the various 
tests which have come to be used can be distributed 
among the three classes : 

I. Urinalysis as an index of renal function. 

A. Urinalysis. 

1. Estimation of water : experimental polyuria. 

2. Estimation of sodium chloride: experimental 

chloruria. 

3. Estimation of urinary nitrogen; urea, etc. 

4. Test meal for nephritic function. 

5. Estimation of urinary coloring matter. 

6. Estimation of urinary diastase. 

B. Physical and biological characteristics. 

1. Cryoscopy of the urine. 

2. Electrical conductivity of the urine. 

3. Estimation of urinary toxicity. 

II. Studies of the blood as indices of renal function. 

1. Estimation of blood urea and of incoagu- 
lable (residual) nitrogen in blood. 



Tests of Kidney Function 81 

2. Ambard's coefficient and the index of urea 

excretion (McLean). 

3. The concentration of creatinin and uric 

acid in the blood. 

4. Estimation of coagulation time. 

5. Cryoscopy of the blood. 

III. Studies of elimination of foreign substances by the 
kidney as criteria of function. 

1. Miscellaneous Chemical Substances. 

a. Potassium Iodide. 

b. Phloridzin. 

c. Hippuric Acid. 

d. Lactose. 

2. Dyes or colors : experimental urinary chromos- 

copy. 

a. Methylene blue. 

b. Indigo carmine. 

c. Phenolsulphonephthalein. 

I. THE STUDY OF URINALYSIS AS AN INDEX OF RENAL 

FUNCTION 

A. Urinalysis 

The urine represents, as it were, the concrete results, 
almost the total results of renal activity. Inasmuch 
as the entire urinary output of the kidney for any given 
period of time may be readily collected it would seem 
natural to assume that a chemical analysis would throw 
all the light that is necessary upon the problem of renal 
function ; but as a matter of fact, while it is true that 
chemical analysis of the urine provides an adequate 
insight into the amount of salts, of water and of urea 
secreted by the kidney, it is not true that urinalyses 



82 Manual of Vital Function Testing Methods 

are sufficient to determine the functional capacity of 
the organ. Gross anatomical and physiological disturb- 
ances are often thus discovered and extremely important 
information is thus derived concerning the diagnosis of 
diseases of the kidney and urinary organs. 

But this is a very different proposition from deter- 
mining thereby the functional capacity or incapacity of 
the kidney, in the absence of evidence of gross organic 
lesion. Even under apparently normal circumstances 
the actual amount of the different urinary constituents 
excreted may vary considerably. For example the 
chlorides may be eliminated in excess and nitrogen re- 
tained or vice versa. But such variations are not neces- 
sarily dependent on anatomical lesions of the kidney 
or even upon any disturbance of renal permeability. 

If, in a given 24-hour specimen of urine, the figures 
representing the elimination of the different important 
constituents depart from the usual normal, we cannot 
draw any absolute conclusions from this fact alone as 
to whether the functional capacity of the kidney is 
below or above normal. One reason for this is that the 
chemical constitution of the urine is not dependent 
alone upon kidney functional power but it is influenced 
by a large number of extremely important extrarenal 
factors, among which may be mentioned the intake of 
food and fluids, the condition of the nervous system and 
other organs, etc. 

It is a well-known fact that before any important 
conclusions as to nitrogen metabolism can be drawn 
from the chemical constitution of the urine, these factors 
must be taken into consideration, and if they are ade- 
quately considered the task becomes complicated by 
many necessary experimental refinements. The whole 
question of body metabolism must be taken up. The 
intake and output in every direction must be measured. 



Tests of Kidney Function 83 

But even after this is done and it is demonstrated from 
urinalysis that there is a deficit in nitrogen excretion, 
the kidney function may be perfect and the nitrogen 
simply retained in the tissues. 

Variations in nitrogen elimination occur under so 
many different conditions that interpretation is often 
difficult or impossible. The same may be said with 
regard to the output of other constituents of the urine. 

Concerning the application of urinalysis to the inter- 
pretation of kidney function it may be said that if the 
figures are all consistently and invariably normal, the 
kidney function is apt to be good; and if there is a 
persistent and considerable departure from normal the 
kidney function may be deficient. 

But in order to be of real value, the tests, particularly 
those regarding the nitrogen excretion, must often as- 
sume the proportion of metabolism experiments, which 
makes them impractical for clinical use. 

Fortunately for the purposes of clinical medicine the 
physician will not be called upon to consider the in- 
tricate problems of nitrogen metabolism in his investi- 
gations of renal function. His desire will be to know 
the capacity of the kidney to do its work and fortu- 
nately this object may be accomplished without recourse 
to extremely elaborate and technical processes. 

We are justified in expecting that under an average 
regimen the kidneys will eliminate somewhere near the 
average amounts of the urinary constituents. But 
knowing how many and how variable the extrarenal fac- 
tors are which influence the absolute quantities of uri- 
nary constituents eliminated, it will become apparent 
that the results of a urinalysis, no matter how complete, 
will require to be supplemented by other and better 
means of determining the functional capacity of the 
kidney. 



84 Manual of Vital Function Testing Methods 

1. Estimation of Urinary Water as an Index of Renal 
Function. Experimental Polyuria. Albarran 9 s Method 

The healthy kidney possesses the power in a high 
degree to adapt itself to those tendencies, such as addi- 
tion or subtraction of water to or from the circulating 
blood, which would tend to alter the molecular concen- 
tration of the fluid. It quickly re-establishes both mo- 
lecular and water equilibrium, thus maintaining an 
equable osmotic tension in the blood and lymph. Super- 
fluous water is, normally, quickly eliminated through 
the glomerulus and reabsorption in the canaliculus is in- 
hibited. When the supply of water to the organism is 
deficient, the resorptive function of the canaliculus is 
raised and a more highly concentrated urine is elimi- 
nated. This function of the kidney may be properly 
termed its diluting-concentrating power. 

Since water secretion is a function of the glomerulus, 
the diluting power of the kidney is a glomerular func- 
tion. The functionally weak kidney is not only unable 
to produce a highly concentrated urine but also unable 
to elaborate a much diluted one. The concentrating 
power of the kidney is a function of the epithelium of 
the uriniferous tubes (canaliculus). 

The diluting-concentrating power of the kidney suf- 
fers in diffuse kidney disease in proportion to the 
amount of parenchyma involved. In parenchymatous 
nephritis the water secreting power of the kidney is 
lowered ; in contracted kidney it is more or less retained. 

The increased urine following an experimental pro- 
vocative polyuria test differs from the increased secre- 
tion following a heavy meal, since in the former case the 
freezing point ( A )> molecular concentration, chloride, 
phosphate and urea content (specific gravity) are all 
diminished, while in the latter they are all increased. 



Tests of Kidney Function 85 

With respect to continuity of function the diseased 
organ possesses a greater constancy and invariability 
in proportion to the amount of disease. The normal 
kidney function tends to vary, that is, to adapt itself to 
the constantly changing conditions in the organism. 
The diseased organ has no such power. 

The healthy kidney always functions below its maxi- 
mum strength; always possesses, in other words, a cer- 
tain reserve power which can be used under extraor- 
dinary circumstances, such as great increase in water 
and solid molecular intake. The insufficient kidney is 
unable to meet these requisitions for added energy, and 
responds but little if at all to extra stimulation. It 
has lost its reserve. 

As a corollary to the above it may be added that if 
one kidney is diseased and the excretion from the two 
organs be compared, the facts as above stated will 
apply. The affected kidney is less able to respond to 
adaptation requirements than the normal and the degree 
of its failure to do so may properly be taken as the 
measure of its incapacity. 

For these reasons polyuria tests may be employed 
with the view of conducting examinations upon the total 
excretion or whenever necessary upon the excretion ob- 
tained by ureteral catheterization from each organ 
separately. 

The Water Tests. — The provocative polyuria tests 
are usually carried out with water. The tests should 
be applied in the morning on an empty stomach. The 
morning urine prior to the test should be measured and 
examined for quantity and specific gravity, total sodi- 
um chloride and urea elimination and perhaps cryo- 
scopically. The patient is then given 500-700 c.c. of 
mineral water or ordinary water. The urine should be 
collected every half hour by voiding or catheter if the 



86 Manual of Vital Function Testing Methods 

total amount is to be examined (general renal function) 
or by ureteral catheterization if the separate kidney 
functions are to be compared. 

Under normal circumstances the polyuria appears 
within the first half hour, reaching its maximum at this 
time, and quickly sinking. The content of solids sinks. 
The freezing point (A) diminishes. 

If the functional power of the organ is below normal, 
the polyuria is delayed or does not occur and the 
amount of variation from the normal may be taken as 
a fair measure of the incapacity. 

Straus-Griinwald Method. — The patient takes noth- 
ing after 7 p. m. into the stomach. At 6:30 a. m. the 
following morning a pint of water is ingested. The 
night urine is collected; also that voided at 7, 8, 9, 10, 
and 11 a. m. The amount and specific gravity of each 
portion are recorded. The patient remains in a reclin- 
ing position during the time of the test. 

In normal cases an amount of urine is passed in the 
first 3 hours equal to that which was drank. That is 
by 10 a. m. at least a pint is voided. At 8 a. m. the 
sp. gr. is lowest. Variations in the amount voided, time 
required, and specific gravity will indicate abnormal 
renal function. 

The Diuretic Tests {pharmacological). — Caffein, 
diuretin, theophyllin (theocin), euphyllin and other 
diuretic substances have been employed, but none of 
these drugs has been found to possess much advantage 
over the simple water test. The diuretic drugs appear 
to increase the solid constituents of the urine as well as 
the fluids. Blum, who introduced euphyllin, does not 
recommend it because he has found a fall of blood pres- 
sure follow its hypodermic or intravenous administra- 



Tests of Kidney Function 87 

tion. 

None of these tests have acquired a sufficient promi- 
nence to justify their description. 

While the so-called water or polyuria tests have 
proven of some value in estimating relative function in 
the separate kidney secretions, it is generally agreed 
that they are of much less importance in estimating 
total kidney function. 

The absolute quantity of urine voided varies very 
greatly under normal and abnormal circumstances. 
According to Rowntree and Fitz there is no constant 
relation between the existence of polyuria or oliguria 
and the condition of kidney function as shown by other 
well-recognized tests. This applies to nephritic and 
cardiac cases and to combinations of these. 

The specific gravity of the urine in advanced nephri- 
tis according to these authors is usually low. 

9. Estimation of Sodium Chloride as an Index of 

Renal Function 

Ten to fifteen grams of sodium chloride are excreted 
by a normal adult in 24 hours. The rapidity with 
which the kidneys can excrete a considerable amount of 
sodium chloride has been suggested and employed as a 
test for renal function. 

With regard to the method of so-called forced elim- 
ination of sodium chloride, it must be ireely granted 
that the problem is a very difficult and complicated one. 

If diminished secretion of sodium chloride always 
indicated renal impermeability the problem would be 
solved, but this is by no means tie case. The tissue 
fluids themselves, everywhere in tb body perhaps, have 
varying affinities for sodium chlo ide and a diminution 
of chloride elimination may not signify a diminished 



88 Manual of Vital Function Testing Methods 

permeability of the kidney for salt but only an increased 
retention of salt in the body. 

Nevertheless there is, under normal circumstances, a 
very close relation between the intake of sodium chloride 
in the food and its elimination by the kidneys. So that 
if an individual is placed for a period of time upon a 
regimen containing a low percentage of salt, the excre- 
tion of that substance will become reduced to a lower 
equilibrium. If now the quantity of sodium chloride 
ingested be suddenly increased there will be an immediate 
and proportionate increase in the amount secreted. 

If there is no increase, it will be difficult to determine 
whether there is chloride retention or defective excre- 
tion so that the chloride test is seldom used alone as a 
measure of renal function. 

The exact situation in the glomerulo-tubular mechan- 
ism where sodium chloride is excreted, is not known 
with certainty. According to the rather recent investi- 
gations of Schlayer and Takayasu and Yon Monakow, 
sodium chloride is excreted by the tubular epithelium, 
or more exactly the excretion of salt following its ad- 
ministration in amounts in excess of the usual daily 
intake is accomplished by the tubules. 

When large amounts of sait are ingested the excre- 
tion, according to Schlayer, takes place in one of two 
ways, depending upon the amount of water simultane- 
ously absorbed. If the salt is given without extra water 
it is almost entirely secreted within 24 hours without 
diuresis, by an increased concentration of the urine. If, 
however, it is ghen with an excess of water it is secreted 
partially through increased concentration and partially 
through diuresis. \ 

If the vascular sVucture of the kidney is injured, 
the ingestion of salt ^ay be followed by marked diure- 
sis, the salt all escaj^ig i n the urine in 24 hours with- 



Tests of Kidney Function 89 

out the percentage content being increased. The spe- 
cific gravity may be low and tends to remain at a fixed 
point. To this combination of phenomena, Schlayer 
gave the name vascular hyposthenuria, and, according 
to his idea, the inability of the kidney to eliminate a 
urine concentrated in salt is not due to tubular defect 
but to a hypersensitive condition of the blood vessels 
which allows the secretion of the salt in relatively large 
amounts of water; in other words, the sensitive vessels 
respond to the salt administration by the diuresis. 
When the vascular injury is more marked the vessels do 
not so react but respond with oliguria. 

In severe tubular epithelial disease, however, the 
quantity of salt eliminated is not raised by the adminis- 
tration of salt. Here a urine of fixed low specific grav- 
ity of moderate quantity is obtained. The salt is re- 
tained. Theie is, according to Schlayer, a tubular 
hyposthenuria, 

These interesting findings reported by Schlayer and 
his school have not been completely corroborated and 
it does not appear to be agreed at the present time that 
any absolute distinction between vascular and tubular 
hyposthenuria can be founded upon the response of the 
kidney to tests witi sodium chloride. 

In fact the number of extrarenal factors concerned 
in the suit output a~e so many and so illy understood 
that the salt test aloie is considered of no value. But 
when considered in conjunction with other functional 
tests and with clinical findings in cardiac and renal 
cases it may be of some diagnostic and prognostic 
value. 

In advanced nephitis there seems no doubt that 
salt elimination is lesened to a certain extent but 
if the patient has beei on a salt-poor diet for a time 
previous to the test, fee tissues will retain salt when 



90 Manual of Vital Function Testing Methods 

administered regardless of the cardiorenal condi- 
tion. 

GEdema is the symptom in chronic nephritis which 
is usually associated with the idea of chloride reten- 
tion. It is not positively known just what factors are 
concerned in this, or whether they are chiefly renal or 
extrarenal. 

It is on the basis of the supposed connection be- 
tween oedema and chloride retention that the now well- 
known method of salt reduction in the treatment of 
oedema in Bright's disease was introduced. 

Technic of Sodium Chloride Test. Test of Alimen- 
tary Chloruria. — The patient is placed on a diet con- 
taining about 5 gms. of salt per day. After several 
days or when the salt output is approximately con- 
stant, 5-10 gms. of sodium chloride are given, dis- 
solved in 125 c.c. of water. The quantity is taken in 
three portions during the day. This is kept up for 
four consecutive days. The daily output of chloride 
is determined by the method described below. If the 
patient is kept on a salt-poor diet, say 2.5 gms. daily 
for some time previous to the test, it vill be found that 
excretion will always be lessened from a normal ten- 
dency of the tissues to retain cHorides. For this 
reason the best method consists in merely establishing 
chloride equilibrium before the testis started. 



Estimation of Sodium Chloridejin the Urine. — The 
principle of the test is that chloifles are precipitated 
by solutions of nitrate of silver] Volhardt's method 
with its various modifications is /egarded as the most 
accurate quantitative method oi chloride estimation, 
and is used when the exact amount must be known as 
in metabolic experiments. 

For all practical purposes IV^hr's method will suf- 



Tests of Kidney Function 91 

fice. 2 The strength of silver solution used in the test 
is such that 1 c.c. corresponds to .01 gm. of sodium 
chloride. Such a solution contains 29.06 gms. of pure 
fused silver nitrate to the liter. The technic of the 
estimation is as follows: 

10 c.c. of urine previously freed from albumen are 
put in an Erlenmeyer flask or porcelain capsule and 
100 c.c. of water added and several drops of potassium 
chromate solution, enough to produce a distinct yel- 
low color. 

The standard silver solution is added from a burette, 
stirring until the reddish orange color which appears 
first where the drop falls is distributed. The first 
permanent orange color trace is the end of the reac- 
tion. The operation should be repeated if necessary, 
to make certain of results. The number of c.c. used 
multiplied by .01 gives the amount of sodium chloride. 
The results are a little high but near enough for prac- 
tical purposes. A rough estimate of the amount of 
chloride in the urine may be made as follows : To a 
test tube of clear urine non- albuminous, add 10 drops 
of pure HNO s and one drop of AgN0 3 (1 to 8). If 
chlorides are normal or increased, the precipitate is 
a compact ball which sinks to the bottom. If dimin- 
ished, the ball is less compact. If much diminished, 
only a cloud is produced without solid flakes. This 
last represents a chloride content of 1% or less. 

3. Estimation of Urinary Nitrogen as an Index of 

Renal Function 

When functional tests of the liver were being dis- 
cussed (v.s.) considerable emphasis was laid upon in- 

2 The Lutke-Martius method is often recommended, see Sahli's 
Diagnostic Methods, 1911, p. 455. 



92 Manual of Vital Function Testing Methods 

terpreting ureagenetic disturbance of that organ by 
taking into consideration the different phases of nitro- 
gen metabolism which are so closely connected with 
liver activity. It was then shown that a knowledge 
of total nitrogen elimination in the urine and particu- 
larly of the different forms in which the nitrogen is 
eliminated, will shed light upon the condition of liver 
functional power. 

The reasons for these assumptions were given in 
their proper place, but it may be serviceable to refer 
again to the fact that the liver is regarded as a very 
important locus for the synthesis of urea in the body. 
For this reason it is quite reasonable to suppose that 
functional depreciation of the liver cells would be re- 
flected to an appreciable extent by the quantitative 
relative variations of the nitrogen constituents of the 
urine. 

When now we come to the significance of nitrogen 
elimination in the urine to disorders of kidney activity, 
it will be necessary to remember that the kidney has 
nothing to do whatever in a specific way with the nitro- 
gen metabolism. Its only function is to excrete the 
nitrogenous waste products which are brought to it 
by the blood. That urea is not manufactured by the 
kidney is proved by the fact that if blood is perfused 
through an isolated kidney, no urea is formed even tho 
substances such as ammonium carbonate, from which 
urea is readily produced, are added to the blood. It 
is well known that if the kidneys are removed in ani- 
mals or their function paralyzed, urea will continue to 
accumulate in the blood as long as the animal sur- 
vives. ! i ^j 

No physiological fact is better known than that 
the relative amount of urea nitrogen in the urine varies 
directly with the amount of protein food ingested. 



Tests of Kidney Function 93 

Other nitrogenous constituents of the urine, the purin 
bodies and creatinin, are unaffected by the intake. This 
suggested to Folin that most of the urea in the urine 
may come directly from food proteins which, having 
been hydrolyzed in the intestine into amino acids, are 
absorbed and further hydrolyzed and oxidized and 
the nitrogen constituent immediately eliminated as 
urea. The liver has most to do with this process though 
the urea forming function of this organ is known to 
be shared by some other tissues since even after the 
removal of the liver some urea is formed. 

These physiological principles being agreed upon, 
it is easy to appreciate that the question of the estima- 
tion of urinary nitrogen as an index of renal function 
will be practically confined to the estimation of the 
amount of urea eliminated under normal circumstances, 
the patient being on a fixed diet, with an estimation 
of the power of the kidney to eliminate more urea when 
the proteid intake is increased, or when urea itself is 
ingested. The question of nitrogen accumulation in 
the blood as an index of renal insufficiency will be dis- 
cussed below, when the study of the blood as an index 
of renal function is considered. It may be admitted 
here that the study of the partition of nitrogen and 
particularly quantitative estimations of urea and in- 
coagulable nitrogen in the blood serum are of much 
greater significance in the estimation of kidney function 
than the same or related studies applied to the urine. 

Diminished and Delayed Excretion of Urea. — This 
is an old criterion of functional renal power. The 
physiological principles upon which it is based have 
just been given. In order that this test of renal func- 
tion shall be really conclusive, the patient must be put 
for some days upon a fixed regimen in which the amount 
of protein is definitely known. 



94 Manual of Vital Function Testing Methods 

The feces and urine must be examined to determine 
what part of the nitrogen has escaped in both. In 
carrying out such procedure, the experiment rises to 
the dignity of a metabolic investigation and requires 
great care and patience besides considerable technical 
skill. For this reason such a procedure cannot be re- 
garded as adapted to clinical use. 

Without the above precautions the value of ordinary 
routine urea estimation in the urine as a criterion of 
renal function is extremely doubtful. 

If the dietary conditions can be reasonably con- 
trolled and a perfectly and persistently normal output 
of urea results, the renal function is at least equal to 
the ordinary demand of that person. If the proteid 
intake is increased and the urea excretion undergoes 
a corresponding and immediate rise, it may be con- 
cluded that the reserve force of the kidney is not 
materially damaged. 

But negative results need not necessarily be taken 
to indicate a defect of renal function because of the 
fact that digestive disturbance and diminished liver 
function will cause the same thing to occur. If # these 
extrarenal factors of error can be eliminated, then a 
diminished output of urea may become a valuable and 
reliable index of renal inadequacy. 

Under a later chapter, concerning study of the blood 
as an index of renal function, it will be shown that the 
quantitative estimation of nitrogen partition in that 
fluid is a much more reliable test of renal functional 
power than urea estimations in the urine. 

Repeating what has been given under general con- 
siderations it may be stated that a normal adult se- 
cretes from 30 to 34 grams of urea in the urine every 24 
hours. 

The simplest quantitative test for urea in urine is 



Tests of Kidney Function 95 

that of Marshall, which has been described (v. s.). 
This method is so simple and so accurate that every 
clinician should familiarize himself with it. 

Forced Urea Elimination. Provocative Urea Test of 
McKasky. — Technic. Thirty grams of urea dissolved 
in four to six ounces of water are given with a small 
breakfast, such as a cup of gruel. Follow this with 
four or five ounces of water to assist diuresis. The 
urine is collected every two hours for twenty-four hours, 
beginning two hours before the urea is given, so that a 
standard for comparison may be had, to determine the 
amount of increase. Quantitative determinations of 
urea are made in the different specimens at the end of 
the time. 

The maximum excretion, its time, incidence, and the 
curve for the 24 hours, is thus determined. 

Under normal conditions there is a sharp rise in 
urea excretion in the second two-hour period. When 
the kidney function is deficient the sharp rise is absent 
or is much delayed. 

The only factor liable to disturb the interpretation 
of this test is gastric stasis. 

Theoretically, the provocative urea test should be 
useful. There does not appear to be any reason why 
the urea could not be injected in smaller amounts, di- 
rectly into the circulation, in which event the liability 
of misinterpretation through retention in the stomach 
would be avoided. The test has not been subjected to 
any clinical examination, so far as I know. 

4. Test Meal for Nephritic Function 

As a composite test for substances normally elimi- 
nated in the urine, and for the observation of the va- 



96 Manual of Vital Function Testing Methods 

riations in specific gravity, the test meal for nephritic 
function now occupies a place of prime importance. 
Hedinger and Schlayer * recently proposed a qualita- 
tive test of the mode of urinary function, as measured 
by the specific gravity, salt and water excretion in two- 
hourly periods. This method of study of kidney func- 
tion has been especially amplified by the work of Mo- 
senthal. His results have been corroborated by the 
writer and many other workers, and the following is 
from his observations and conclusions. The original 
name of "nephritic test meal" was recently changed to 
the "test meal for nephritic function" at the sugges- 
tion of L. F. Barker. 

The following form contains the directions for the 
test meal: 

Diet 

test meal for nephritic function 

For Date 1 

All food is to be Salt Free food from the kitchen. 

Salt for each meal is to be furnished in weighted 
amounts. One capsule of salt, containing 2.3 gm. so- 
dium chloride, is furnished with each meal. The salt 
which is not consumed is returned to the laboratory, 
where it is weighed, and the actual amount of salt taken 
calculated. 

All food or fluid not taken must be weighed or meas- 
ured after meals, and charted in the spaces below. 

Allow no food or fluid of any hind except at meal 
times. 

Note any mishaps or irregularities that occur in 
giving the diet or collecting the specimens. 



Tests of Kidney Function 97 

Breakfast, 8 A. M. 

Boiled oatmeal, 100 gm 

Sugar, 1/2 teaspoonful 

Milk, 30 c.c 

Two slices bread (30 gm. each) 

Butter, 20 gm 

Coffee, 160 c.c 

Sugar, 1 teaspoonful ^ 

Milk, 40 c.c 

Milk, 200 c.c 

Water, 200 c.c 

Dinner, 12 Noon. 

Meat soup, 180 c.c 

Beefsteak, 100 gm 

Potato (baked, mashed or boiled), 130 gm. . . . 

Green vegetables as desired 

Two slices bread (30 gm. each) 

Butter, 20 gm 

Tea, 180 c.c 

Sugar, 1 teaspoonful 

Milk, 20 c.c 

Water, 250 c.c 

Pudding (tapioca or rice), 110 gm 

Supper, 5 P. M 

Two eggs, cooked any style 

Two slices bread (30 gm. each) 

Butter, 20 gm 

Tea, 180 c.c 

Sugar, 1 teaspoonful 

Milk, 20 c.c 

Fruit (stewed or fresh), 1 portion 

Water, 300 c.c 



98 Manual of Vital Function Testing Methods 

8 A. M. — No food or fluid is to be given during the 
night or until 8 o'clock the next morning (after void- 
ing), when the regular diet is resumed. 

Patient is to empty the bladder at 8 A. M. and at 
the end of each period, as indicated below. The speci- 
mens are to be collected for the following periods in 
properly labeled bottles: 

8 A. M.— 10 A. M. ; 10 A. M.— 12 N. ; 12 N.— 2 P. 
M. ; 2 P. M.— 4 P. M. ; 4 P. M.— 6 P. M. ; 6 P. M.— 
8 P. M. ; 8 P. M.— 8 A. M. 

The dietary, as above given, contains approximately 
13.4 gm. of nitrogen, 8.5 gm. of salt and 1760 c.c. 
water, and considerable purin material in the meat, 
soup, tea and coffee. All of these substances act as 
diuretics. It is on the manner of response to these 
stimuli that this test of renal function depends. It is 
not essential that all meals be eaten completely, nor ex- 
actly as indicated. In private patients it will suffice 
for the patient to eat three full meals, making approxi- 
mate note of quantities, as one cup coffee, etc. While 
the above liberties may be taken, it is of special impor- 
tance that the urine be collected accurately during the 
stated periods, that no solid or liquid food be taken 
between meals, and especially none at night, and that 
the 12 hour night specimen be completed before break- 
fast. The normal Xidkoey responds so rapidly to the 
ingestion of fluid that these precautions are necessary. 

The quantity and specific gravity of each specimen 
is determined. Originally, the salt and nitrogen in 
each specimen were estimated, but it was found suffi- 
cient to make the determination only for the total day 
and night specimens. 

The important facts to be observed are as follows: 

1. Characteristics of the day urine. 

2. Quantity of water, salt and nitrogen eliminated 



Tests of Kidney Function 99 

in 24 hours. 

3. Characteristics of the night urine. 

1. Day Urine. — The day urine shows a rhythmical 
response to each meal, in that the quantity of fluid in- 
creases at these periods. The diuretic response to the 
test meal was not found as constant as stated by 
Hedinger and Schlayer, and for this reason no great 
stress was put on it, due to its irregularity. However, 
a fixed or constant two hourly specimen has proved 
of some diagnostic moment. The specific gravity 
should not be fixed, but should vary inversely to the 
quantity. 

2. Quantity of Water, Salt and Nitrogen Elimi- 
nated in %4 Hours. — Under normal conditions, the uri- 
nary output should be about 400 c.c. less than the 
fluid intake, which allows for the excretion by the skin, 
lungs and intestines. Nitrogen elimination should ac- 
count for 90 per cent, of the nitrogen intake, the re- 
mainder passing out in the feces. Sodium chloride is 
entirely excreted in the urine, except in diarrhea. A 
marked deviation from the above figures should always 
cause an investigation of the patient's habits for the 
past few days. These may show a diet which necessi- 
tates the retention or excretion of one or more of these 
substances. Any marked variation suggests a more ex- 
tended study. Of more importance is the concentration 
of salt and nitrogen. A normal kidney can easily con- 
centrate nitrogen and salt above 1 per cent. ; an ab- 
normal kidney often cannot. 

3. Night Urine. — Observations of the night urine 
are only of value when no solid or liquid food is taken 
during that interval. It varies within narrow limits 
no matter what the day specimens show. It should be 
small in amount, of high specific gravity and of high 
concentration in nitrogen. 



100 Manual of Vital Function Testing Methods 

The important points to be noted in the urine of 
normal individuals on the test meal for nephritic func- 
tion are : 

1. Variations in the specific gravity of the 2 hourly 
specimens, usually 9 points or more. (In case of di- 
minished water intake and oliguria, the variations may 
be somewhat less.) 

2. An approximate balance between the output 
and intake of salt, nitrogen and fluids. 

3. A night urine of high specific gravity (1.016 — 
1.018 or higher) of high nitrogen concentration (1 per 
cent, or more) and small in amount (400 c.c. or less) 
regardless of the fluid ingested or the amount of urine 
voided during the day. 

Normal Reaction to Nephritic Test Meal. 



Time of Day 

8-10 
10-12 
12- 2 
2- 4 
4- 6 
6- 8 


Urine 
c.c. 
153 
156 
194 
260 
114 
238 


Sp. Gr. 
1.016 
1.019 
1.012 
1.014 
1.020 
1.010 


^-Sodium Chlorid— -* 
Per Cent. gm. 

1.32 2.02 
1.25 1.95 
0.64 1.24 
0.77 2.00 
0.99 1.13 
0.43 1.02 


< Nitrogen * 

Per Cent. gm. 

0.89 1.26 
0.74 1.15 
0.59 1.14 
0.56 1.46 
0.95 1.08 
0.52 1.23 


Total day 
Night, 8-8 .. . 


1,115 
375 


i;620 


0]63* 


9.36 
2.36 


i!23 


7.32 
4.61 


Total 24 hours 
Intake 


1,490 
1,760 







11.72 
8.5 





11.93 
13.4 


Balance 


+ 270 




. . . . 


—3.22 


.... 


+1.47 



Impression: Normal reaction to the nephritic test 
meal. Note the variations occurring in the fluid out- 
put, and the specific gravity, which are in inverse ratio ; 
the night urine, which is small in amount and shows a 
high specific gravity and a high percentage of nitro- 
gen; and the approximately normal output of water, 
salt and nitrogen in twenty- four hours. (After Mosen- 
thal.) 



Tests of Kidney Function 101 



Normal Reaction to Nephritic Test Meal 



Time of Day 

8-10 
10-12 
12- 2 

2- 4 

4- 6 
6- 8 


Urine 
c.c. 

240 
482 
244 
290 
120 
420 


Sp. Gr. 

1.018 
1.010 
1.019 
1.010 
1.017 
1.007 


--Sodium Chlorid— > 
Per Cent. gm. 


< Nitrogen . 

Per Cent. gm. 


Total day .... 
Night, 10-8 . . 


1,796 
352 


i'.6i7 


0.66 
0.58 


11.84 
2.16 


0.41 
1.20 


7.36 

4.22 


Total 24 hours 
Intake 


2,148 
1,760 







14.00 
8.50 




11.58 
13.40 


Balance 


—388 




. . . . 


—5.50 


.... 


+1.82 



Impression: Normal reaction to the nephritic test 
meal. In this case, polyuria is evident. This is prob- 
ably due to the reaction in an individual who is accus- 
tomed to a bland diet and not to the quantities of salt 
and purins taken with the test meal. (After Mosen- 
thal.) 

The Urinary Response to the Test Meal in Disease. — 
The normal kidney possesses the power of concen- 
trating and diluting the urine, and readily answers 
the demand for either, in order to maintain the body 
fluids at the proper concentration. The kidney ex- 
presses its diminished power to functionate by a fixa- 
tion of concentration. The loss of this flexibility has 
been called "hyposthenuria" by Koranyi. The result is 
a fixation of specific gravity. Such a fixation of spe- 
cific gravity occurs in a kidney which is the seat of a 
nephritis. It is of great importance to remember, how- 
ever, that extrarenal conditions may cause a reduction 
of renal function with a resulting fixation of specific 
gravity. Such conditions are pyelitis, cystitis associ- 
ated with prostatic hypertrophy, hydronephrosis, pyo- 



102 Manual of Vital Fwnction Testing Methods 

nephrosis, polycystic kidneys, renal congestion due to 
cardiac disease, diabetes insipidus, severe anaemias, and 
possibly other conditions. A constancy or fixation in 
the quantity of liquid or other constituents have not 
yielded anything of particular value. An impaired 
renal function may show a retention of one or more of 
the urinary constituents under observation, namely, 
water, salt and nitrogen. In no instance has the com- 
bination of retention of nitrogen with sufficient salt 
excretion been encountered. 

Nycturia (an increased amount of urine at night, 
above 400 c.c), not pollakiuria (increased frequency 
of urination) is to be regarded as one of the earliest 
signs of nephritis. It is present when the only other 
signs are a trace of albumin and an occasional hyaline 
cast. Occasionally, a nocturnal polyuria is present 
for which no organic lesion can be found. Possibly this 
may be a functional change which exhibits itself as the 
first symptom of kidney disease. It is always to be 
remembered that functional and anatomical diagnoses 
do not always keep pace, especially in the early 
stages. 

Results with Complete Test Meals. — Chronic Inter- 
stitial Nephritis. — The points indicating renal insuf- 
ficiency in these examples of this condition vary with the 
intensity of the pathological condition, and are as fol- 
lows: 

1. Fixed and low specific gravity. 

2. Diminished output of both salt and nitrogen. 

3. Tendency to total polyuria. 

4. Night urine showing a slight or marked increase 
in volume; low specific gravity; low concentration of 
nitrogen. 



Tests of Kidney Function 



103 



Early Hypertensive Nephritis 



Time of Day 
8-10 
10-12 
12- 2 
2- 4 
4- 6 
6- 8 


Urine 
c.c. 
465 
102 
205 
160 
116 
160 


Sp. Gr. 
1.009 
1.014 
1.009 
1.010 
1.014 
1.006 


-— Sodium Chlorid— > 
Per Cent. gm. 

0.51 2.37 
0.62 0.63 
0.32 0.66 
0.28 0.44 
0.48 1.55 
0.09 0.14 


* Nitrogen > 

Per Cent. gm. 
0.34 1.58 
0.77 0.79 
0.44 0.90 
0.64 1.02 
0.80 0.92 
0.29 0.46 


Total day ... . 
Night, 8-8 .. . 


1,208 
935 


iioio 


6!33 


4.79 
3.08 


6.50 


5.67 
4.67 


Total 24 hours' 2,143 
Intake 1,760 






7.87 
7.50 




10.34 
13.40 


Balance 


—383 




■ . a . 


—0.37 


.... 


+3.06 



Impression: The nephritic test meal shows a ten- 
dency toward fixation of specific gravity and a distinct 
nocturnal polyuria in an early case of hypertensive 
nephritis. (After Mosenthal.) 



Reaction to Nephritic Test Meal in Advanced Hypertensive Nephritis 







Urine 






^—Sodium Chlorid—- 




-Nitrogen — 




ime of Day 


c.c. 


Sp 


. Gr. 


Per Cent. 


gm. 


Per Cent. 


gm. 


8- 


10 


133 


1 


.010 


0.36 


, 0.48 





.35 





.47 


10-12 


176 


1 


.009 


0.36 


0.63 





.34 





.60 


12- 


2 


156 


1 


.010 


0.32 


0.50 





.35 





.55 


2- 


4 


212 


1 


.009 


0.36 


0.76 





.34 





.72 


4- 


6 


164 


1 


.009 


0.38 


0.62 





.36 





.59 


6- 


8 


104 


1. 


010 


0.33 


0.34 


0. 


33 


0. 


34 



Total day ... . 945 
Night, 8-8 .. . 590 


i!6io 


6i34 


3.33 
2.01 


6'.38 


3.27 
2.24 


Total 24 hours 1,535 
Intake 1,510 




— 


5.34 
5.80 




5.51 
12.20 



Balance 



25 



+0.46 



+6.69 



Impression: Reaction to the nephritic test meal in 
a case of advanced hypertensive nephritis. There is 
very marked fixation of the percentage figures for ni- 
trogen and salt concentration and the specific gravity. 
There is evident nitrogen retention. The salt intake is 
too low to make it certain that a diminished ability to 
excrete salt does not exist. (After Mosenthal.) 



104 Manual of Vital Function Testing Methods 






Extreme Interstital Nephritis 



Time of Day 

8-10 
10-12 
12- 2 
2- 4 
4- 6 
6- 8 


Urine 
c.c. 

24 

106 

82 

83 



230 


Sp. Gr. 
1.005 
1.006 
1.007 
1.008 

i!668 


<— Sodium Chlorid-^ 
Per Cent. gm. 


* Nitrogen » 

Per Cent. gm. 


Total day .... 
Night, 6-8 .. . 


525 
1,140 


i'.6o7 


0.12 
0.12 


0.63 
1.37 


0.25 
0.20 


1.28 
2.27 


Total 24 hours 
Intake 


1,665 
1,850 




.... 


2.00 
6.00 





3.55 
13.00 


Balance 


+ 185 




.... 


+4.00 


.... 


+9.45 



Impression: Reaction to the nephritic test meal in 
a case of extreme interstitial nephritis. Note the low 
fixed specific gravity, the retention of salt and nitrogen, 
and the night urine, which is increased in amount, 
shows a low specific gravity and a low nitrogen con- 
centration. (After Mosenthal.) 

The above results may be simulated by various dis- 
ease conditions, which may be summarized as follows: 

1. Causes in the urinary passages: pyelitis, cysti- 
tis, prostatic hypertrophy. 

2. Causes in the blood: marked anemia. 

3. Causes in the kidney (organic or functional): 
pyelonephritis, polycystic kidneys, diabetes insipidus. 

A thorough etiologic search is therefore of great im- 
portance, especially as regards prognosis. 

Renal Congestion {Myocardial Insufficiency). — The 
following are points characteristic of acute myocardial 
decomposition : 

1. Specific gravity markedly fixed at the level of 
about 1.020. 

2. A diminished output of salt. The low percent- 
ages for sodium chloride are striking. 

3. An adequate nitrogen output. The very high 



Tests of Kidney Function 105 

concentration of nitrogen is in marked contrast to that 
of salt. 

4. An oliguria. 

5. A night urine normal in character. 

Urine in Extreme Cardiac Decompensation 

Urine < — Sodium Chlorid-^ - Nitrogen > 

Time of Day c.c. Sp. Gr. Per Cent. gm. Per Cent. gm. 

8-10 61 1.018 0.20 0.12 1.52 0.93 

10-12 52 1.020 0.24 0.12 1.83 0.95 

12-2 65 1.019 0.26 0.17 1.73 1.12 

2-4 55 1.018 0.27 0.15 1.65 0.90 

4- 6 30 1.020 0.26 0.07 1.61 0.48 

6- 8 35 1.021 0.40 0.14 1^80 0.63 

Total day.... 298 0.77 5.01 

Night, 8-8 . . 275 1.021 0.31 0.85 1_ 1 8£ 5.07 

Total 24 hours 573 1 . 62 10 . 08 

Intake 570 ._ 5.00 .__^ 12.00 

Balance — 3 +3.38 +1.92 

Impression: Nephritic test meal in an extreme case 
of cardiac decompensation. Note the high concentra- 
tion of nitrogen as compared to the low figures for salt. 
There is distinct oliguria. (The water output should 
be higher as general anasarca was present.) (After 
Mosenthal. ) 

Hypertensive nephritis complicated by myocardial 
decompensation is a symptom complex met with so fre- 
quently that it demands special attention. As a rule 
the picture of renal congestion predominates, but oc- 
casionally it cannot "break through" the barrier im- 
posed by the contracted kidney. 

Hypertensive Nephritis Complicated by Myocardial Insufficiency 

Urine -—Sodium Chloride > Nitrogen » 

Time of Dav c.c. Sp. Gr. Per Cent. gm. Per Cent. gm. 

8-10 85 1.016 0.41 0.34 1.09 0.93 

10-12 83 1.017 0.31 0.26 1.14 0.94 

12- 2 100 1.017 0.41 0.41 1.04 1.04 

2- 4 100 1.017 0.41 0.41 1.04 1.04 

4- 6 106 1.016 0.46 0.49 0.92 0.98 

6- 8 80 1.020 0.35 0.28 1.16 0.92 

Total day .... 554 2 . 19 5 . 85 

Night, 8-9 . . 405 1.018 0.10 0.40 1.07 4.33 

Total 24 hours 959 2 . 59 10 . 18 

Intake 1,375 7.50 ._ 1 _^ 8.80 

Balance + 416 +4.91 —1.38 



106 Manual of Vital Function Testing Methods 

Impression : Test meal curve in a case of hyperten- 
sive nephritis complicated by myocardial insufficiency. 
The low salt and high nitrogen elimination are char- 
acteristic of renal congestion, as is the high fixed spe- 
cific gravity. It shows how the influence of renal con- 
gestion may "break through" the functional picture 
presented in hypertensive nephritis. (After Mosen- 
thal.) 

During the period of elimination of edema, as might 
be expected from the polyuria existing at that time, the 
following characteristics are to be found: 

1. Specific gravity low and somewhat fixed. 

2. Nitrogen elimination normal. 

3. Salt and water excretion exceed the amount in- 
gested. 

4. The night urine is increased in amount, has a 
low specific gravity, and a low percentage of nitrogen. 

Cardiac Decompensation Recovery, Eliminating Edema 

Urine --Sodium Chlorid-^ Nitrogen » 

Time of Day c.c. Sp. Gr. Per Cent. gm. Per Cent. gm. 

8-10 142 1.012 

10-12 114 1.015 

12- 2 144 1.010 

2- 4 224 I/. 015 

4- 6 178 1.013 

6- 8 216 1.010 

Total day.... 1,018 0.51 4.68 0.44 4.03 

Night, 8-8... 966 1.012 0.51 4.93 0.71 6.82 

Total24hours 1,984 9.61 10.85 

Intake 1,230 ..... 8.50 13.40 

Balance — 754 .... —1.11 .... +2.55 

Impression: Nephritic test meal from a case of 
cardiac decompensation while eliminating edema fluid. 
Note the low and rather fixed specific gravity, the elimi- 
nation of large amounts of salt and fluid and a night 
urine increased in quantity with a low specific gravity 
and a low percentage of nitrogen. (After Mosenthal.) 

When all of the edematous fluid has been eliminated, 



Tests of Kidney Function 107 

the urinary function does not immediately assume the 
normal type, as is usually supposed. During this 
period the urine passed resembles somewhat the char- 
acteristics of that of chronic interstitial nephritis, and 
seems to indicate that congestion has definitely im- 
paired the function of the kidney, at least for a time. 
The following points are to be noted: 

1. Low moderately fixed specific output. 

2. Normal water and nitrogen output. 

3. Slightly diminished salt output. 

4. The night urine may or may not be increased, its 
specific gravity and nitrogen concentration is low. 

Full Cardiac Compensation Following Decomposition 

Urine .—Sodium Chloride Nitrogen * 

Time of Day c.c. Sp. Gr. Per Cent. gm. Per Cent. gm. 

8-10 198 1.005 0.27 0.54 0.27 0.53 

10-12 108 1.006 0.42 0.45 0.41 0.44 

12- 2 41 1.011 0.58 0.24 0.60 0.24 

2- 4 95 1.009 0.54 0.51 0.59 0.43 

4-6 46 1.009 0.43 0.20 0.79 0.36 

6-8 70 1.010 0.61 0.43 0.74 0.52 

Total day.... 558 .... 2.37 .... 2.52 

Night, 8-8... 515 1.011 0.51 2.63 0.53 2.70 

Total24hours 1,073 .... 5.00 .... 5.22 

Intake 1,360 6.60 6.00 

Balance + 287 .... +1.60 .... +0.78 

Impression: Nephritic test meal from an individual 
with full cardiac compensation following a period of 
decompensation. The figures show considerable devia- 
tion from the normal: low, moderately fixed specific 
gravity, slightly diminished salt output, nocturnal 
polyuria with a low specific gravity and low concen- 
tration of nitrogen. (After Mosenthal.) 

Chronic Diffuse (Parenchymatous) Nephritis. — The 
urinary findings in this type of nephritis are as variable 
as the clinical picture. During the period of edema 
formation the test meal shows marked salt and water 
retention, nocturnal polyuria and a good nitrogen elim- 



108 Manual of Vital Function Testing Methods 

ination. Such urines resemble very closely those seen 
in myocardial decompensation (except the nocturnal 
polyuria in this type), and usually require clinical data 
for a differentiation. This is usually easy. However, 
the nocturnal polyuria usually helps to indicate a par- 
enchymatous nephritis. During the elimination of 
edema, the picture is similar to that of myocardial 
decompensation under like conditions. 

Chronic Diffuse Nephritis 





Urine 




< Sodium Chlorid— n 


> Nitrogen » 


Time of Day 


c.c. 


Sp. Gr. 


Per Cent. 


gm. 


Per Cent. 


gm. 


8-10 


32 


1.025 










10-12 















12- 2 


54 


1.024 










2- 4 


64 


1.033 










4- 6 


64 


1.028 










6- 8 


66 


1.030 










Total day ... . 


280 




0.18 


0.50 


1.91 


5.34 


Night, 8-8... 


595 


1.016 


0.08 


0.48 


0.93 


5.53 


Total 24 hours 


875 






0.98 




10.87 


Intake 


1,760 






8.50 




13.40 


Balance 


+885 




.... 


+7.52 




+2.53 



Impression : Nephritic test meal in a case of chronic 
diffuse nephritis during the period of edema forma- 
tion. The marked salt and water retention, the noc- 
turnal polyuria and high nitrogen excretion are char- 
acteristic. (After Mosenthal.) 

Chronic Diffuse Nephritis 





Urine 




^—Sodium Chlorid-^ 


> Nitrogen » 


ime of Day 


c.c. 


Sp. Gr. 


Per Cent. 


gm. 


Per Cent. gm. 


8-10 


230 


1.022 


1.16 


2.66 


1.15 2.64 


10-12 


130 


1.025 


1.08 


1.40 


1.42 1.85 


12- 2 


118 


1.022 


1.01 


1.19 


1.21 1.43 


2- 4 


136 


1.022 


1.14 


1.44 


1.25 1.70 


4- 6 


96 


1.020 


0.70 


0.68 


1.18 1.13 


6- 8 


108 


1.014 


0.80 


0.87 


0.89 0.96 



Total day .... 818 
Night, 8-8... 950 


i'.oii 


6*78 


8.24 
7.61 


6.73 


9.71 
7.14 


Total 24 hours 1,768 
Intake 1,760 






15.85 
8.50 




16.85 
13.40 



Balance 



•7.35 



—3.45 



Tests of Kidney Function 109 

Impression: Results of the nephritis test meal in 
a case of chronic diffuse nephritis, while eliminating 
edema. Note the large amounts of fluid, salt and ni- 
trogen excreted. (After Mosenthal. ) 

In Mosenthal' s series it was interesting to note an 
occasional case showing many of the symptoms of 
nephritis, and a normal response to the test meal. The 
converse is also occasionally to be found. 

Summary. — Quoting Mosenthal : 

"The nephritic test meal, as suggested by Hedinger 
and Schlayer, and elaborated in this paper, has not 
only proved itself to be an admirable test for renal 
function, but also in many cases has been of great 
value in diagnosing cardiac, renal and other conditions. 
Much pleasure and profit may be derived from a study 
of diseases of the kidney from this point of view, since 
it forms a basis for a rational therapy, and stimulus 
toward keen clinical observation." 

Note: The salt was estimated by the Volhardt method, the 
nitrogen by the Kjeldahl process. 

* References: Mosenthal: Archives Int. Med., 1915, 
XVI, 733-774 ; Hedinger and Schlayer : Deutsch. Arch, 
f. klin. Med., 1914, cxiv, 120; Koranyi and Richter: 
Physiakalische Chemie und Medizin, Leipzig, 1908, ii, 
136-152. 



5. Estimation of Urinary Coloring Matter as Test 
of Renal Function 

Thudichum 9 s Test. — This test is now of only histor- 
ical interest. It was proposed by its author on the 
clinical ground that in many chronic kidney diseases 



110 Manual of Vital Function Testing Methods 

the urine becomes distinctly paler in color. Therefore 
careful quantitative estimations of color excretion 
might be of value as an early sign of renal imper- 
meability. But unfortunately for the value of the test, 
the quantity of coloring matter excreted in the urine 
depends upon a great variety of factors (liver, intes- 
tine, food, etc.), of which the most insignificant of all 
is perhaps renal permeability. 

6. Estimation of Urinary Diastase as an Index of 

Renal Function 

Wohlgemuth' 's Test. 3 — Technic. After neutraliza- 
tion urine is placed by means of an accurately grad- 
uated pipette in a series of twelve test tubes, the amount 
decreasing from .6 c.c., .5 c.c, A c.c, to .1 to .09 c.c, 
.08 c.c, to .04 c.c. A sufficient quantity of 1% sodium 
chloride solution is then added, to bring the amount of 
fluid in each tube up to 1 c.c. In order to more readily 
obtain the fractional quantity of urine required, 1 c.c. 
of the urine may be diluted up to 10 c.c. and from this 
diluted urine the required measures may be taken. 

To each tube is added 2 c.c. of a 1-1000 solution of 
freshly prepared soluble starch. The tubes are im- 
mersed in a water bath at 38° C. for 30 minutes, after 
which they are placed in cold water for 3 minutes. 

To each tube is then added sufficient 1/50 normal 
iodin solution to elicit a permanent color, violet or blue 
occurring where digestion is not complete. 

The tube in the series immediately preceding incom- 
plete digestion of the starch indicates the diastase 
content of that particular urine. From this is calcula- 
ted the diastasic activity represented by S. Sis expressed 
as the number of c.c. of 1/10% starch solution which 

8 Lancet Clinic, 1913, CX, p. 164. 



Tests of Kidney Function 111 

can be digested by 1 c.c. of urine. This test can be 
applied to the whole urine or to the samples obtained 
unilaterally by ureteral catheterization. The diastase 
test is particularly adapted to unilateral estimations 
of kidney function applied to urine obtained by ureteral 
catheterization. But altho it is capable of indicating 
in the majority of cases which is the diseased or more 
diseased kidney, in the opinion of most genitourinary 
surgeons it is not necessary and adds nothing to the 
information obtained from the phthalein test or urea 
estimations, which latter are operations somewhat more 
easily performed. 

The diastase test has never been used to any extent 
in estimating total functional capacity of the kidneys. 

B. The Study of Physical and Biological Character 
istics of the Urine as Criteria of Renal Function 

There are three tests which come under this category : 

1. Cryoscopy or determination of the freezing point 
of the urine. 

2. Electrical conductivity of the urine. 

3. Determination of urinary toxicity. 

1. Cryoscopy of the Urine. Significance for Estimat- 
ing Renal Function. Von Koranyi's Test 

The theoretical bases upon which this test is founded 
are of extreme interest both from physical and physio- 
logical points of view but naturally cannot be com- 
pletely considered here. 

The freezing point of distilled water is zero. The 
freezing point of any solution is below zero, and the 
depression of freezing point below zero is proportionate 
to the molecular concentration of the solution. Conse- 



112 Manual of Vital Function Testing Methods 

quently the freezing point of a solution is a measure of 
its molecular concentration. It is also a measure of its 
osmotic pressure. 

The freezing point of a solution is independent of 
the nature, size, and molecular weight of the dissolved 
molecules and is only dependent on their number. The 
specific gravity of a solution is on the contrary de- 
pendent upon the nature and molecular weight of the 
dissolved molecules. Solutions of similar molecular con- 
centration have the same freezing point and the same 
osmotic pressure but not necessarily the same specific 
gravity. 

By cryoscopy the molecular concentration of urine 
and blood can be estimated and in this way a certain 
insight into the functional power of the kidney can be 
obtained, since the global function of this organ is to 
regulate the osmotic pressure, or, what is the same, 
the molecular concentration of the blood. One can 
obtain from an estimation of the lowering of the freez- 
ing point of the urine below the zero of distilled water 
a somewhat more adequate idea of the functional ca- 
pacity of the kidney than from the specific gravity. 4 

Of two urines of equal specific gravity the one with 
the lower freezing point comes from the better func- 
tioning kidney. 

Investigations have shown that the freezing point 
of the urine ( A ) in health varies between rather wide 
limits (A= — .90° to — 2.30°) and that it is to 
some extent affected by miscellaneous factors of extra- 
renal nature. 

Altho much was expected originally from the de- 
termination of the freezing point (cryoscopy) of urine 

4 Some authors do not agree that cryoscopy is superior to sp. 
gr. estimation in determining renal permeability, v. Sahli, Diag- 
nostic Methods, 1905, p. 551. 



Tests of Kidney Function 113 

in estimating the integrity of renal function, it is not 
depended upon to any great extent at present. 

The molecular concentration of the blood hence its 
freezing point ( 8 ) is much more constant than that 
of the urine. It is supposed to remain somewhere 
near — .56°. It was thought that insufficiency of renal 
function by allowing the accumulation of molecules 
in the blood which should be excreted would raise the 
molecular concentration therein or, in other words, 
lower the freezing point. Unfortunately, experience 
has not confirmed the hopes of those who thought that 
cryoscopic examinations of the urine and blood would 
solve the great problem of estimating the renal func- 
tions and the method is not extensively used. 

The relation between the lowering of freezing point 
of blood (8 ) and urine (A) was proposed by Dreser as 
a measure of the work done by the kidney and by 
Bernard as the basis of a sort of mathematical con- 
ception of the eliminatory power of the kidney. The 

g 
formula — XV-R will represent the molecular 

elimination of the kidney according to this conception. 
8 represents the freezing point of urine, A that of 
the blood, V the quantity of urine in 24 hours. In 
normal cases R varies from 3000 to 5000, whereas in 
renal insufficiency these numbers are considerably re- 
duced. Unfortunately all attempts to reduce our con- 
ceptions of organic function to mathematical terms 
have not been eminently successful. 

Technic of Cryoscopy. — The technic of cryoscopy 
is not especially complex but requires a certain ap- 
paratus for its performance. It is usually carried 
out in the laboratory and has never become a routine 
clinical procedure. Only the necessary outlines of 
the method need here be given since those who desire 



114 Manual of Vital Function Testmg Methods 

to master it can easily refer to numerous texts in 
which the technique is minutely described. 5 

The technic of cryoscopy is carried out with Beck- 
mann's freezing apparatus carrying a special ther- 
mometer. The freezing mixture is made of ice, water 
and salt. In the freezing mixture is plunged an ordi- 
nary thermometer and a mixer, thus enabling the tem- 
perature to be kept at a fixed point ( — 3° to — 5°). 
Through an opening a tube containing the special ther- 
mometer immersed in the liquid to be frozen can be 
immersed in the freezing mixture. The estimation 
of the exact points of freezing is not difficult and 
usually the operation can be performed in its entirety 
in 15 or 20 minutes. 

2. Electrical Conductivity of the Urine 

The electrical conductivity of the urine in health 
and disease was first studied by Turner. The electrical 
conductivity is estimated in ohms of resistance and 
depends upon the number of ions of salts dissolved 
in the urine. The method measures, in other words, 
the amount of salts or mineral content of the fluid. 
The Kohlrausch method of performing the test, which 
is the one usually employed, requires a whetstone 
bridge, a resistance box, telephone and cells, besides 
other paraphernalia, and partly on account of this 
complexity and also the fact that the practical results 
obtained are meagre, the test has never come into gen- 
eral use. 

5 Consult in this connection Wood's Chemical and Microscopical 
Diagnosis, 1909, p. 61; Sahli's Diagnostic Methods, p. 546. 



Tests of Kidney Function 115 

3. Estimation of Urinary Toxicity as a Test of Renal 

Function 

Bouchard's Test. — It was for a long time believed 
that the toxicity of the urine was proportional to the 
functional power of the kidney. Urine of human be- 
ings produces symptoms of poisoning and death when 
injected intravenously into lower animals. Bouchard 
developed from this fact a method of testing renal 
function 6 by determining the quantity of a 24-hour 
specimen of urine, required to kill a kilogram of lower 
animal. Bouchard established a so-called urotoxic co- 
efficient which was that quantity of poison elaborated 
by every kilogram of body weight of the person whose 
urine was tested. 

The same objections exist with respect to the theo- 
retical basis of this test, as in the case of chemical 
urinalysis previously discussed, namely that so many 
factors besides renal sufficiency or insufficiency enter 
into the production of results that the test becomes 
devoid of scientific value. It simply shows the toxicity 
of a given urine injected intravenously into a given 
animal and by no means reflects the actual functional 
power of the kidney through which it was derived. The 
test is quite complex and has been abandoned. 

H. STUDIES OF THE BLOOD AS CRITERIA OF RENAL 
FUNCTION. ESTIMATION OF BLOOD UREA AND OF IN- 
COAGULABLE (residual) NITROGEN IN BLOOD 

When it is considered that a major portion of the 
nitrogenous waste of the body makes its escape through 
the kidney by way of the urine, it becomes evident that 
a diminution of the functional capacity of these organs 

6 Also toxopexic liver function (t\ s.). 



116 Manual of Vital Function Testing Methods 

must often result in an accumulation of nitrogenous 
products of metabolism in the blood. 

Such an idea is very old and as long ago as 1821 
Prevost and Dumas 7 reported an increase of urea in 
the blood after extirpation of the kidneys in animals. 
The clinical importance of their experiments was rec- 
ognized by Bright in his observations upon nephritis 
in 1836. 8 

After B right's time it became well recognized that 
in chronic nephritis there may be a tendency toward 
accumulation of nitrogenous matters in the blood, but 
the quantitative study of nitrogen retention was forced 
to await the development of accurate chemical methods 
of investigation. In this place we can speak only of 
modern technic. 

The development of accurate technic in nitrogen 
estimation of the blood and its application to clinical 
medicine is a subject which has been perfected only 
since the beginning of the century. Ascoli, 9 Strauss 10 
and others showed that in many cases of chronic 
Bright's disease nitrogenous matter accumulates in the 
blood and the increase is more marked as death ap- 
proaches. Muller n showed that in outspoken uremia 
the accumulation becomes proportionately more 
marked. 

Obermayer and Popper 12 first laid stress upon the 
increase of incoagulable nitrogen in the blood serum 
in uremic states and found that in this incoagulable 
nitrogen increase, urea plays the most important part. 

7 Quoted by Schondorff in Pfliiger's Archiv f. de ges. Physiol., 
1899, LXXIV, p. 307. 

8 Guy's Hosp. Rep., 1836, I, p. 358. 

Pfliiger's Arch. f. de ges. Physiol., 1901, LXXXVII, p. 103. 
10 Chronisch Nierenenzundung ; ihrer Einwirkung auf die Blut- 
flussigkeit, etc., Berlin, 1902. 

n Verh. d. Deutsch. path. Gesell., 1904-5, VII to IX, Erg. 80. 
13 Zeit. f. klin. Med., 1909, LXVII, p. 332. 



Tests of Kidney Function 117 

Hohlweg 13 substantiated these facts and altho he 
showed that an increase of urea in the blood is not 
necessarily pathognomonic of uremia, nevertheless its 
accumulation therein may be regarded as an evidence 
and to some extent at least as an index of the function 
of the kidneys. 

Widal, 14 however, believes that the amount of urea 
retention is an actual quantitative index of renal func- 
tion and that the severity and prognosis of a given 
case may be predicated upon the basis of such findings. 
Widal' s clinical method of estimating urea in the blood 
is not commonly used in this country as it gives, ac- 
cording to Rowntree and Fitz, an error of 10 to 60% 
and is therefore useless as a quantitative method. 

The estimation of urea in blood serum has remained 
until recently a rather difficult chemical operation, but 
of late one or two , practical clinical methods have been 
devised which render the test much more practical. 
Marshall's method appears to be the simplest and 
most practical of these and will be described in full 

The normal figures for the elimination of urea are 
between .300 to .500 gm. per liter of serum. 

The simplest methods by which the total incoagulable 
nitrogen in the blood serum may be determined still 
remain even more difficult and complicated than those 
of urea estimation, especially since they involve in the 
end a nitrogen determination by Kjeldahl's method. A 
fair laboratory equipment is therefore necessary. 

The most practical method of determining the in- 
coagulable nitrogen seems to be that of Hohlweg 
and Meyer which has been modified by Morris 15 in 

13 Deut. Archiv f. klin. Med., 1919, CIV, p. 216. 
14 Bull, et Mem. Soc. Med. d. hop. de Paris, 3, 1911, XXXII, p. 
627. 
^Archiv. of Int. Med., 1911, VIII, p. 457. 



118 Manual of Vital Function Testing Methods 

this country. This method will be described below. 
The normal figures for total incoagulable nitrogen in 
the blood serum are .500 to .600 gm. per liter. 

The recent work of Folin and Denis indicates that 
a urea concentration in the blood of .5 gm. and total in- 
coagulable nitrogen content of .6 gm. per liter, which 
was formerly considered normal, is too high an esti- 
mate. They found the normal urea concentration .13 
gm. and incoagulable nitrogen .26 gm. per liter. In 
their experience no great prognostic significance is to 
be attached to urea concentration of less than .55 gm. 
per liter and incoagulable nitrogen less than .50 gm. 
per liter. Greater concentration than this, especially 
if the freezing point of the serum drops lower than 
— 60 are of considerable prognostic significance. 

In pure passive congestion Rowntree states that he 
has never seen the rest nitrogen in the blood serum 
higher than .63 gm. per liter. 

Marked accumulation of incoagulable nitrogen or 
of urea in the blood is now regarded as a valuable 
evidence of renal insufficiency and in cases of nephritis 
it is an unfavorable prognostic sign. 

The relation between non-protein (incoagulable) ni- 
trogen retention in the blood and the excretion of phe- 
nolsulphonphthalein has been studied in experimental 
uranium nephritis by Frothingham, Fitz, Folin and 
Denis. 16 These investigators found that the results of 
the two tests paralleled very closely. For this reason 
and because in clinical studies the same parallelism has 
been found to obtain, these two tests have come to be 
considered as among the best for conjoint use. 

It will now be necessary to give the simplest, most 
practical and accurate methods by which the clinical 
investigator may determine the two important phases 

16 Arch, of Int. Med., 1913, XIII, p. 24,5. 



Tests of Kidney Function 119 

of the blood which have been discussed, namely, the 
amount of urea in the blood and the amount of in- 
coagulable or rest nitrogen contained in the same fluid. 
The chemical operations which are used at present for 
these purposes are simple enough to bring about their 
frequent use in the clinic. The best method of quickly 
and accurately determining the amount of urea in the 
blood is that of Marshall. The incoagulable or rest 
nitrogen in blood serum is usually determined by either 
of two general methods, that of Hohlweg-Meyer and 
that of Folin and Denis. The details of these three 
important methods will now be given. 

Marshall's Method for the Determination of Urea 
in the Blood. 17 — The blood is drawn in the usual man- 
ner and allowed to stand on ice until clotting is com- 
plete. As shown below, the urea content of the sehim 
does not change after standing even for three or four 
days ; the blood can, therefore, be kept on ice over 
night, if desired. 

Two equal portions of the serum are measured into 
ordinary test tubes, 1 c.c. of the soy bean extract 18 
added to one tube, and about 0.5-1.0 c.c. of toluene to 
each. If sufficient serum is available, 10 c.c. portions 
should be used; however, perfectly satisfactory results 
can be obtained by using 5 c.c. or even 3 c.c. portions 
of the serum. The tubes are tightly stoppered and 
allowed to remain at room temperature until the con- 
version of the urea into ammonium carbonate is com- 
plete. Generally, they are allowed to stand over night, 

17 Jour, of Biol. Chem., 1913, XV, No. 3. 

"The preparation of the soy bean extract is as follows: Ten 
grams of finely ground soy beans are treated with 100 c.c. of water 
and allowed to stand with occasional agitation for one hour. 10 c.c. 
of j^ hydrochloric acid are added and the mixture allowed to 
stand about fifteen minutes longer. It is now filtered and pre- 
served with toluene. Such a solution is perfectly satisfactory for 
use at least five or six days after its preparation. 



120 Manual of Vital Function Testing Methods 

altho four to five hours is usually amply sufficient for 
the completion of the reaction. The contents of the 
tube containing the serum and extract are transferred 
to cylinder A (see illustration), and washed in with a 
very small amount of water (not more than 5 c.c). 
Two grams of sodium chloride, an equal volume of al- 
cohol and a layer of kerosene oil are added to the cylin- 
der. The contents of the other tube are transferred to 




cylinder B, and treated in exactly the same manner. 25 



n 



c.c. 



of — hydrochloric acid and about 25 c.c. of water 



are placed in each of the 200 c.c. Erlenmeyer flasks 
used for the absorption of the ammonia. The different 
parts of the apparatus are now connected and about 0.5 
gram of sodium carbonate added to each cylinder. A 
rapid air current is passed through the apparatus until 
all the ammonia has been removed from the cylinders. 
With a good suction pump, one hour suffices. The 



Tests of Kidney Function 121 

excess of acid in the absorption flasks is titrated with -zjl 

sodium hydroxide and alizarin sodium sulphonate. The 
amount of acid neutralized in the flask attached to 
cylinder B corresponds, of course, to the ammonia 19 
present in the serum, while the amount used in the other 
two flasks represents the urea plus the ammonia. The 

difference corresponds to the urea in terms of tt: 

hydrochloric acid, and multiplied by 0.0006 gives the 
urea in grams present in the amount of serum taken 
for the determination. 

Details in Connection With the Apparatus and De- 
termination. — 1. On account of the large quantity of 
protein in serum, it is advisable to use both alcohol and 
kerosene to prevent foaming. 20 

2. The tubes C and C are ordinary calcium chlor- 
ide drying tubes packed loosely with cotton. These 
in conjunction with the bulbs prevent any splashing 
or mechanical transmission of the alkali into the ab- 
sorption flasks. While the bulbs are probably not 
absolutely necessary, they are convenient in keeping 
the cotton filters dry. 

3. For the better absorption of the ammonia, the 
tubes in the Erlenmeyer flasks are closed at one end, 
and pierced with six or seven small holes, as suggested 
by Folin. 21 Even with this device one absorption flask 
is not always sufficient to completely absorb the am- 
monia. Two flasks are always used for safety in con- 

19 We can, however, place no value on this as a determination of 
the true ammonia content of the blood, for on standing even a 
few hours the blood develops much more ammonia than the 
original amount (Folin). 

20 This has been pointed out by Folin, in connection with the use 
of the air current method for determining ammonia in blood. 
(Zeitsch. f. physiol. Chem., XXXVII, p. 165, 1902-03.) 

21 Jour. Biol. Chem., XI, p. 493, 1912. 



122 Manual of Vital Function Testing Methods 

nection with the urea determination; however, since 
from the serum alone only a very small amount of am- 
monia (corresponding to 0.10-0.70 c.c. of -rx HC1) 

is ordinarily obtained, one absorption flask is here 
sufficient. 

4. A layer of toluene is placed on the liquid in the 
absorption flasks, for, due probably to the alcohol car- 
ried over by the air current, considerable foaming some- 
times occurs. If not prevented, this results in a loss 
of a portion of the contents of the flask. 

5. The bottle contains dilute sulphuric acid to free 
the air from any traces of ammonia before passing it 
through the apparatus. 

6. No correction is necessary for the ammonia de- 
rived from the 1 c.c. of soy bean extract used, as the 
amount obtained from this source is unappreciable. 

Another method also suggested by Dr. Marshall is 
to draw 5 c.c. of blood from a vein with a hypodermic 
needle, into a 5 c.c. pipette, and immediately transfer 
the specimen to a test tube, containing 1 to 2 c.c. of 
1% sodium oxalate solution. To this is added 25 
milligrams (one tablet) of Urease-Dunning, the tablet 
having been previously crushed and dissolved in 5 c.c. 
of water. This mixture is allowed to stand until the 
urea of the blood is decomposed; at ordinary room 
temperature, one-half an hour is usually sufficient; it 
is better, however, to place the test tube in a beaker 
of water at 30° to 40° C. for one-half hour. After the 
urea has been changed, the contents and sufficient wash- 
ings of the tube are transferred to a cylinder. The 
ammonia is then removed by a current of air collected 

in the — hydrochloric acid and titrated with 77: 
50 J 50 

sodium hydroxide. 



Tests of Kidney Function 123 

Calculating Urea Content. — As the purpose in using 
Urease-Dunning is to convert the urea present in a 
specimen into an easily estimated substance — am- 
monium carbonate — and as the amount of this salt 
produced from this source, by the enzyme, is indicated 
by the increased alkalinity of the specimen to methyl 
orange, it is obvious that the quantity of standard 
hydrochloric acid required to exactly neutralize the 
contents of the flask containing urease, less the quan- 
tity required for the control specimen, corresponds to 
the ammonium carbonate formed by the conversion of 
the urea originally present in the specimen. 

By the following equation: 

NH 2 ONH 4 

CO +2H 2 0=CO 

NH 2 ONH 4 

it may be calculated that 60 grams of urea would be 
converted, by urease, into 96 grams of ammonium car- 
bonate, which amount would require 72 grams of hydro- 
chloric acid to neutralize it. 

As this quantity (72 grams) of hydrochloric acid 
is contained in 20,000 c.c. of decinormal (N/10) hydro- 
chloric acid solution and is equivalent to 60 grams of 
urea, as represented by 96 grams of ammonium car- 
bonate, it follows that one twenty- thousandth of this 
quantity or 1 c.c. of decinormal hydrochloric acid 
would be equivalent to one twenty- thousandth of 60 
grams = 3 milligrams (60 -f- 20,000 = .003), there- 
fore each c.c. of decinormal hydrochloric acid required 
to neutralize an enzyme-treated specimen, that is in 
excess of the number of cubic centimeters required to 
neutralize the control specimen, represents three milli- 
grams of urea, and, as the 5 c.c. specimen is the one 
two-hundredth part of a liter, it will be only necessary 



124 Manual of Vital Function Testing Methods 

to multiply the number of c.c. of the decinormal hydro- 
chloric acid solution, in excess of the control's require- 
ments, by the factor .6 (.003 X 200 = .6) to ascer- 
tain the urea per liter, when estimating the daily output. 

1. Technic of Estimating Total Incoagulable or So- 
called Rest or Residual Nitrogen in the Blood Serum 

Two methods are in common use. These are Morris 5 
modification of the Hohlweg-Meyer method, and the 
method of Folin and Denis. 

Morris 9 Modification of Hohlweg-Meyer Method. — 
To 10 c.c. of blood serum obtained by venipuncture or 
otherwise, in a 300 c.c. Erlenmeyer flask is added a 
reagent consisting of equal parts of 1% acetic acid 
and a 5% solution of monocalcium phosphate, until the 
reaction is acid to litmus but neutral to Congo red. 
The volume is brought up with distilled water to 80 
c.c. and 80 c.c. of saturated solution of sodium chloride 
are poured into the flask. 

The mixture is boiled to precipitate the coagulable 
proteins, and the filtrate, from which the proteins have 
been shown to be completely removed, subjected to a 
nitrogen determination by Kjeldahl's method. 

For a description of the technic of KjeldahPs method 
see page 32. 

Folin and Denis Method. — This method is considered 
at the present time as the most practical way of quan- 
titatively determining the amount of rest nitrogen in 
the blood. It will be given in the words of its authors 
from their communication published in 1912. (Jour. 
Biol. Chem. 1912, XI, 527, Ibid. 1913, XIV, 29.) 

Method for Drawing Blood. — "Before going into de- 
tails of the chemical work it would seem worth while 
to describe our method of drawing blood because so 



Tests of Kidney Function 125 

far as we have been able to learn it is somewhat different 
from the procedures employed by physiologists and 
because we believe it to be expeditious, neat and exact 
and therefore particularly suitable for quantitative 
work. 

"We use neither cannula? nor syringes but simply 
hypodermic needles and pipettes. The needles are about 

1 mm. in diameter, and about 25 mm. long. They are 
immersed in a dilute solution of vaseline in ether and 
then allowed to drain and dry on a clean paper for 
a few minutes before being used. (This does not apply 
of course to the drawing of human blood when the 
needles must be thoroughly sterilized.) An adequate 
supply of these needles is kept on hand so that we do 
not need to use any needle more than once in any one 
experiment. The needle is attached to the tip of a 

2 or 5 c.c. pipette by means of a short piece of narrow 
pure gum tubing. A small pinch of powdered potas- 
sium oxalate is introduced into the upper end of the 
pipette (which must be clean and perfectly dry) and 
is allowed to run down into the tip and the needle. The 
other end of the pipette is connected with a rubber 
tube which in turn connects with a mouthpiece con- 
sisting of a short tapering glass tube. Close to the 
pipette the rubber tube carries a pinchcock. 

"To draw the blood insert the needle in the vein or 
artery and regulate the flow of the blood by means of 
the pinchcock and by suction. The exact quantity of 
blood desired is thus obtained without any waste and 
without clotting." 

Isolation of Non-Protein Nitrogenous Constituents. 
— "To separate the non-protein nitrogenous constitu- 
ents from the protein materials we make use of pure 
(acetone- free) methyl alcohol and an alcoholic solu- 
tion of zinc chloride. Ordinary methyl alcohol cannot 



126 Manual of Vital Function Testing Methods 

be used because the impurities in it, particularly the 
acetone, combine with more or less of the urea so that 
it escapes decomposition in the subsequent treatment 
and is not quantitatively recovered. We have satisfied 
ourselves by means of determinations on pure urea 
solutions that the presence of acetone results in a loss 
of urea. 

"As soon as the blood is drawn it is transferred into 
measuring flasks half filled with methyl alcohol and the 
flasks are then filled up to the mark with methyl alcohol 
and vigorously shaken. Two cubic centimeters of blood 
are diluted to 25, while for 5 c.c. of blood use 50 c.c. 
flasks. At the end of two hours, or as soon after that as 
is convenient, the contents of the flasks are filtered 
through dry filters. To the filtrate are then added two 
or three drops of a saturated alcoholic solution of zinc 
chloride and after standing for a few minutes the mix- 
ture is again filtered through a dry paper. The zinc 
chloride brings down an appreciable precipitate and the 
last traces of coloring matters so that when the second 
filtration is made, a perfectly colorless filtrate is ob- 
tained. 5 c.c. of these filtrates, corresponding to 0A 
or to 0.5 c.c. of blood, depending on whether 2 or 5 
c.c. of blood were drawn, are taken for each determina- 
tion. 

"The precipitation procedure described above is the 
one which we ordinarily use. There are objections to 
it. We are not certain that protein-like materials may 
not escape precipitation by this as by every other 
method and we do know that the filtrate does not con- 
tain all of the non-protein materials. When relatively 
large quantities (equivalent to 100 mgm. of nitrogen 
per 100 c.c. of blood) of creatine or asparagine are 
added to blood and treated as described above there is 
invariably an appreciable loss of material. To over- 



Tests of Kidney Function 127 

come this loss we have tried to triturate and wash the 
first alcoholic precipitate with methyl alcohol, and with 
some substance as, for example, with glycocoll, urea 
and acetamide, we are thus able to get practically 
quantitative results, while with others, such as creatine, 
asparagine and tyrosine, we still do not get quite all. 
Moreover, such trituration and washing does leach out 
a small amount of the coloring matters of the blood 
so that except for special experiments with less soluble 
substances we consider the simpler procedure rather 
more satisfactory. 

Determination of the Total Non-Protein Nitrogen. — 
"To determine the non-protein nitrogen of the blood 
5 c.c. of the alcoholic filtrate is transferred to a large 
Jena test tube. One drop of sulphuric acid, one of 
kerosene and a pebble are added and the methyl alcohol 
is driven off by immersing the test tube in a beaker 
of boiling water for five to ten minutes. When the 
alcohol is removed 1 c.c. of concentrated sulphuric 
acid, a gram of potassium sulphate, and a drop of 
copper sulphate solution are added and the mixture is 
boiled, cooled and diluted. 

"From this digestion mixture the ammonia is removed 
in the usual manner. It is, however, not collected di- 
rectly in a measuring flask (as in urine analysis) but 
in a second large test tube previously charged with 1 

c.c. of r^: acid added to 3 c.c. of water. The reason 

for this variation is that 0.4 to 0.5 c.c. of blood con- 
tains only 0.1 to 0.2 mgm. of non-protein nitrogen. 
The final Nesslerized solution cannot be diluted to 100 
c.c. and smaller volumetric flasks cannot be used as re- 
ceivers during the air current treatment because of 
spattering. Large test tubes are therefore used as 
receivers and the ammonia is Nesslerized in these before 



128 Manual of Vital Function Testing Methods 

the liquids are transferred to measuring flasks. 

"Ordinarily the colored solutions when obtained from 
cat's blood are transferred to 25 c.c. flasks and are then 
found to have a depth of color which permits of a 
sure and accurate reading in the colorimeter. In some 
of our absorption experiments the total non-protein 
nitrogen runs up to very high figures and then the solu- 
tions are diluted to 50, sometimes even to 100 c.c, be- 
fore being read in the colorimeter. 

"Human blood contains scarcely more than one-half 
as much non-protein nitrogen as cat's blood. In the 
case of human blood we therefore never draw less 
than 5 c.c. and we take 10 c.c. of the filtrate for 
each determination. In all other respects we use 
the same procedure for human blood as for cat's 
blood. 

"In all ordinary cases 7 to 8 c.c. of diluted Nessler's 
reagent (dilution 1:5) are added for the production 
of the color. If much ammonia is present so that the 
resulting colored solution must be diluted to 50 or 100 
c.c. correspondingly larger amounts of Nessler's reagent 
are added. 

"The calculation of the analytical results to milli- 
grams of nitrogen per 100 c.c. of blood is not difficult, 
but the formulas given below may prove useful. In 
these formulae, the standard solution contains 1 mgm. 
of nitrogen (as ammonium sulphate) Nesslerized in a 
100 c.c. flask and the colorimeter prism of the standard 

is set at 20 millimeters, ^r X D> in which R stands 

for the reading of the unknown and D represents the 
volume to which its ammonia has been diluted, gives 
the desired figure. The reason for the figures is that 
we are working with 4 c.c. of blood. 

"When 5 c.c. of blood is taken and it is diluted to 50, 



Tests of Kidney Function 129 

40 
the formula becomes — X D« 

ix 

"When working with human blood and taking 10 c.c. 

of the filtrate obtained from 5 c.c. of blood diluted to 

20 
50 the formula is — X D« 

It 

"It may be thought that we are using unnecessarily 
small amounts of blood in these analyses. We are, 
however, by no means sure that working with larger 
amounts would yield more accurate results and we have 
satisfied ourselves by scores of duplicate analyses that 
the method as outlined gives trustworthy figures. 
Further, the smaller the quantity of blood which can 
be made to give reliable results the greater becomes 
the usefulness of the method. The work which we 
have already done on cats could not have been done 
on such a small animal except by means of these micro- 
chemical methods. Finally, small amounts of blood 
must be used for the urea determinations because of 
the disturbing effects of the sugar present, 



55 



#. Ambard's Coefficient of Urea Excretion and the 
Index of Urea Excretion (McLean) 

It has been proven that the excretory activity of the 
kidney cannot be measured by estimations of the blood 
urea or rest nitrogen alone. The concentration of 
urea in the blood varies within wide limits. The line 
of demarcation between the normal and abnormal in- 
dividual is not sharp, as very frequently an individual 
with impaired urea function will show a blood urea 
within the upper normal limits. Therefore, only the 
more marked instances of impaired renal function will 
be demonstrated by blood urea estimations. Even the 
blood urea of nephritic subjects is not fixed or con- 



130 Manual of Vital Function Testing Methods 

stant. It has been demonstrated that the concentra- 
tion of the urea in the blood may be varied at will by 
the diet. Appreciating these variations, Ambard be- 
gan a study of urea excretion in which the concentra- 
tion of the urea was determined in both the blood and 
urine. He also added determinations of the rapidity 
with which urea elimination occurred. All these fac- 
tors, which are interdependent, are included in his es- 
timations. He formulated what are now known as Am- 
bard's laws, and demonstrated a constant ratio be- 
tween the concentration of urea in the blood and thfe 
rate of excretion. This numerical constant is known 
as Ambard' s coefficient, and is usually indicated by the 
symbol "k." When applied to normal individuals, re- 
markably constant values are obtained with the coeffi- 
cient. In pathologic subjects, there is an increase in 
the concentration of the urea in the blood and a rela- 
tive decrease in the rate of excretion. Ambard has 
shown these relative changes to produce a marked 
change in the urea coefficient. Ambard's work has 
been repeatedly confirmed. 

The principles underlying Ambard's a laws and co- 
efficient, and McLean's modification are expressed very 
clearly and concisely by Smith in a recent publication.^ 
He is quoted below. 

Ambard found that: 

1. When the concentration of the urea in the urine 
is constant, the rate of excretion varies directly as the 

a Ambard, L. : Rapports entre le taux de P'uree dans le sang et 
Pelimination de Puree dans Purine, Compt. rend. Soc. de biol., Nov. 
19, 1910, p. 411; Rapports de la quantite et du taux de Puree dans 
Purine, la concentration de Puree du sang etant constant, ibid., 
Dec. 3, 1910, p. 506; Physiologie normale et pathologie des reins, 
Paris, 1914. 

t> Smith, R. L. I., Renal Function in Nephritis, Jour. A. M. A., 
1917, lxviii, 278. 



Tests of Kidney Function 131 

square of the concentration of urea in the blood. This 
law is expressed: 

(Urea in blood) 2 

= Constant 

Rate of excretion 

2. When the concentration of urea in the blood is 
the same, the rate of excretion varies inversely as the 
square root of the concentration in the urine. 



Rate of excretion I V Concentration II 



Rate of excretion II V Concentration I 



or, Rate I V Concentration I = Rate II V Concentration II 

Introducing this factor into the first law we have : 

Urea in blood 

■ — ■ — ■ — — ■ ■ — ' — ' — ' — ■ — ' — > — ■ — • — ■ — > — ■ — > — ■ — ■ — ■ — • = Constant 



Rate of excretion V Concentration in urine 

3. Other factors remaining constant, the rate of 
excretion varies directly with the weight of the indi- 
vidual. 

Rate 

= Constant 

Weight 

Combining this with the previous formula, we have: 

Concentration of urea in blood 



= Constant 



/; 



Rate 



V Concentration in urine 



Weight 

This formula expresses all of Ambard's laws in the 
simplest form. In order to standardize the formula for 
use in human subjects, Ambard expresses it as fol- 
lows: 

Ur 
■ ■ = Constant (k) 



|/d x — j/— 

f Wt T 25 

Ur = Grams of urea per liter of blood. 
D = Grams of urea excreted per twenty-four hours. 
Wt = Weight of individual in kilograms. 
C — Grams or urea per liter of urine. 

See note c, page 133. 



132 Manual of Vital Function Testing Methods 

This formula is known as Ambard's coefficient, and 
the value of k usually found in the normal human 
subject is 0.08 (McLean). The introduction of a 
standard weight of 70 kg., a standard concentration of 
25 gm. per liter of urine and the expression of excre- 



too 

330 
160 
140 

120 

100. 

80 

60 

40 
10 
















n 


*.y 




















2S 


30 


Z 


4- 


6 


3 


10 


IZ 


14 


16 


1« 


2.0 


tt 


*t 


J>6 


SLS 


50 


1 












































I 




































/ 


1 


































i 
t 


t 


































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i 


i 


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r 








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l 

t 












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Chart 1. — Normal: solid line, milligrams of urea per hundred c.c. 
of blood; broken line, grams of urea excreted per twenty- four 
hours; dotted line, index of urea excretion. This chart shows the 
variations as found by McLean in a healthy adult. 

tion as the rate per twenty-four hours are purely arbi- 
trary, and do not affect the general relationship be- 
tween the variable factors. When these arbitrary fac- 
tors are kept constant, they, in conjunction with the 
constant relationship between the four variable factors, 
tend to keep k constant, and the actual numerical 



Tests of Kidney Function 



133 



value of k is determined by these arbitrary additions 
to the formula: 

Index of Urea Excretion. — To obviate the necessity 
of an arbitrary scale for the interpretation of Am- 
bard's coefficient, McLean c has adopted a formula 
from Ambard's laws, based on a scale of 100 so that 
the rate of urea excretion is given in per cent, of the 
normal, an index of 100 corresponding to a value of 
0.08 for Ambard's coefficient. 

The derivation of the index is as follows : 



Rate of excretion 



Index 



X 100 



Standard normal rate 

From Ambard's laws : 

Ur 



1. K 



Rate = 



Ur 1 



0.08 



Ur 



2. 0.08 = 



V Normal rate 



Normal rate = 



Ur 



0.08 



Rate 



3. 



Normal rate 



4. Index = 100 X 



' Ur ' 

i k 


2 

[0.08] 2 


r 

10.08 
0.08 

k 


' 2 

J 
2 


r 0.08] 
k 


) 

2 



Substituting for k (Ambard's coefficient) and sim- 
plifying, 



Gm. urea per 24 hrs. VGm. urea per liter urine X 8.96 
Index = 

Wt. in kg. X (Gm. urea per liter of blood) 2 
When k = 0.08 the standard normal. Index = 100. 

c McLean and Selling: Urea and Total Non-Protein Nitrogen in 
Normal Human Blood: Relation of Their Concentration to 
Rate of Elimination, Jour. Biol. Chem., 1914, 19, 31. McLean, F. 
C: The Numerical Laws Governing the Rate of Excretion of Urea 
and Chlorides in Man, Jour. Exper. Med., 1915, 22, 212, 366; 
Clinical Determination of Renal Function by an Index of Urea 
Excretion, The Journal A. M. A., Feb. 5, 1916, p. 415. 



134 Manual of Vital Function Testing Methods 

Methods. — Specimens: The methods recommended 
by McLean have been used with slight modification. 
The observations may be made at any time, since the 
application of the laws is independent of the nitrogen 
intake. However, it has been considered preferable as 
a routine to make the observations in the forenoon, no 
food or water being taken during the period. 

The patient is given 300 c.c. of water to drink. One 
half hour later the bladder is emptied, by catheter if 
necessary, and the time noted. Then after one or two 
hours the bladder is again emptied, the time carefully 
noted, and the amount of urine measured to within 1 
c.c. The shorter period is used when the patient is se- 
creting a fairly large amount of urine. At about the 
middle of the period, 10 c.c. of blood are drawn from a 
vein into a dry tube containing about 1 grain of po- 
tassium oxalate, with which it is mixed to prevent clot- 
ting. 

Analysis: The urease method introduced by Mar- 
shall has been used. This depends on the breaking 
down of urea into ammonia and carbon dioxid by the 
specific enzyme found in soy bean and the subsequent 
determination of the ammonia. The permanent prepa- 
ration of urease described by Van Slyke and Cullen € 
has been used throughout. Three analyses were made 
in each case: blood urea, urine urea and urine ammo- 
nia. The urine ammonia is determined in order to cor- 
rect the urea figure for preformed ammonia, which is 
also determined in the urea method. 

d Marshall, E. K., Jr. : A Rapid Clinical Method for the Estima- 
tion of Urea in Urine, Jour. Biol. Chem., 1913, xiv, 283; A New 
Method for the Determination of Urea in Blood, ibid., 1913, xv, 
487; The Determination of Urea in Urine, ibid., 1913, xv, 495. 

eVan Slyke, D. D., and Cullen, G. E.: A Permanent Prepara- 
tion of Urease and Its Use in the Determination of Urea, Jour. 
Biol. Chem., 1914, xix, 211; id., The Journal A. M. A., May 16, 1914, 
p. 1558. 



Tests of Kidney Function 185 

Calculation of the Index: From the results of the 
determinations the following calculations are made: 

1. Grams of urea excreted per 24 hours = D. 

2. Grams of urea per liter of urine = C. 

3. Grams of urea per liter of blood = Ur. 



These values in the body weight in kilos are substi- 
tuted in the formula for the index as given above, and 
the value of the index calculated by aid of a slide rule. 
With the modified slide rule described by McLean it 
may easily be calculated in fifteen seconds. 

Nitrogen Intake. — It has been clearly demonstrated 
that while the nitrogen intake has a direct and marked 
influence on the concentration of blood urea, it has no 
effect on the index of urea excretion. 

The character of the diet in this series has been 
included in the tables after each observation. The diet 
noted as "nephritic" is one which is low in protein and 
sodium chlorid. 

Many workers, including McLean, prefer a 72- 
minute period, as it is one-twentieth of 24 hours, mak- 
ing the mathematics more simple, and is long enough 
to insure accuracy. Even a 36-minute period may 
suffice, but it is a little too short for accurate work. 

While the application of this with other functional 
methods will be discussed in the summary, it might be 
well to state here that many cases of kidney involve- 
ment, especially chronic nephritis, with hypertension, 
show a blood urea without normal bounds, and yet show 
a decided impairment of renal function by the index of 
urea excretion. 



136 Manual of Vital Function Testing Methods 



UREA INDEX SLIDE RULE 




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Tests of Kidney Function 137 

S. Creatinin and Uric Acid Estimations in the Blood 

According to Chase and Meyers, although consid- 
erable attention has been given to the urea and non- 
protein nitrogen of the blood, in nephritis, scant con- 
sideration has been accorded uric acid and creatinin. 
Despite the fact that most of the nitrogen is eliminat- 
ed in the form of urea, it does not necessarily follow 
that studies concerning the fate of uric acid and creat- 
inin are unimportant and uninteresting. They do 
not believe that it is possible to draw satisfactory de- 
ductions regarding nitrogen metabolism from the urea 
and non-protein nitrogen determinations alone. Both 
Mosenthal and Foster have referred to the fact that 
the increase in the non-protein nitrogen in the blood 
in nephritis is entirely insufficient to account for the 
amount of nitrogen retention. Despite this fact, the 
degree of retention of the various waste products af- 
fords an excellent index of the severity of the condi- 
tion, and probably a fair index of the retention in the 
late stages of the disease, particularly as regards the 
uric acid and creatinin. 

In the studies of the above named authors it was soon 
noted that high uric acid estimations were often found 
without any other retention, while creatinin appeared 
to be retained only in the last stages of the disease. It 
was also observed that the kidney was able to concen- 
trate the creatinin 100 times, the urea 80 times, but the 
uric acid only about 20 times. It appears, therefore, 
that normally creatinin is the most readily, and uric 
acid the least readily, eliminated by the kidney, urea 
maintaining an intermediate position. It might be pos- 
sible to offer the hypothesis, then, that the uric acid re- 
tention is the first to become evident, urea the next, and 
creatinin the last. This has proven to be true by ex- 



138 Manual of Vital Function Testing Methods 

perience. 

Accordingly, a retention of uric acid should consti- 
tute one of the early signs of incipient interstitial ne- 
phritis, while a considerable creatinin retention should 
indicate a grave functional impairment of the kidney, 
and should be a valuable prognostic test. 

Theoretically, the amount of the increase in the cre- 
atinin of the blood should be a safer index of the per- 
meability of the kidney than either the urea or the uric 
acid, for the reason that creatinin on a meat-free diet 
is entirely endogenous in origin, and its formation ( and 
elimination normally) very constant. Urea, on the 
other hand, is largely exogenous under normal condi- 
tions, and its formation, therefore, is subject to great 
fluctuations, the same being true in a measure of uric 
acid. The handicap of a high creatinin accumulation, 
the kidney is apparently never able to overcome. As al- 
ready noted, a rise in the concentration of the uric acid 
of the blood appears to be an excellent early sign of 
chronic (interstitial) nephritis. As a prognostic test, 
the blood creatinin has been found to be of very great 
value. It appears to be of more value than the phenol- 
sulphonphthalein test, which remains continuously neg- 
ative, while the changes in the blood creatinin clearly 
show the patient's condition. 

The normal findings are uric acid, from 2 to 3 milli- 
grams per 100 c.c. of blood, and creatinin, from 1 to 
2.5 milligrams per 100 c.c. of blood. Blood creatinin 
estimations of 5 milligrams or more per 100 c.c. of 
blood, practically indicates a fatal termination in a 
comparatively short period. 

References : Chase and Meyers : Journal A. M. A., 
1916, lxvii, 933 ; Meyers and Lough, Arch. Int. Med., 
1915, xvi, 536; Fine, Postgraduate, 1914, xxix, 440. 



Tests of Kidney Function 139 

Methods for the 'Estimation of the Creatinin and 
Uric Acid in the Blood. — The following methods for the 
creatinin determination are those given by Meyers and 
Lough : 

"In most of our work the Duboscq colorimeter has 
been utilized for the estimation of the creatinin and 
creatin somewhat after the technic by Folin. About 
10 c.c. of blood are drawn directly from a vein into a 
small bottle containing a little powdered potassium 
oxalate or 5 drops of a 20% solution to prevent clot- 
ting. Six c.c. of the well mixed blood are treated with 
24 c.c. (4 volumes) in a 50 c.c. centrifuge tube. 
After the corpuscles have been laked, about 1 gram 
of dry picric acid is added, and the mixture stirred 
at intervals with a glass rod until it is a light yellow. 
When the protein precipitation is complete, the tube is 
centrifuged and the supernatant fluid filtered through 
a small 7 cm. filter paper. From 17 to 21 c.c. of fil- 
trate are usually obtained (5 c.c. of which are re- 
moved for the creatin estimation and 3 c.c. for the 
sugar estimation, if these determinations are to be car- 
ried out). To 10 c.c. of the filtrate is added 5 c.c. 
of 10% sodium hydroxide, and a similar amount of al- 
kali added to 10 c.c. of standard creatinin in satu- 
rated picric acid (containing 0.2, 0.5 or 1.0 mg. creat- 
inin to 100 c.c. of picric acid). Creatinin may now 
readily be prepared perfectly by the admirable method 
of Benedict. A standard solution of this creatinin, 
1 mg. to 1 c.c, is kept in 0.1 N hydrochloric acid. 
From this we have prepared a stock solution in picric 
acid, 5 mg. to 100 c.c. by diluting 5 c.c. to 100 c.c. 
with saturated picric acid. By pipetting 0.4, 1.0 or 
2.0 c.c. of this solution into 10 c.c. graduates with 
a Mohr pipette and diluting to the mark, standards of 



140 Manual of Vital Function Testing Methods 

the above strength are prepared. For the Duboscq 
colorimeter the standard prism can conveniently be set 
at the 15 mm. mark. 

"The estimation of the creatinin may likewise be car- 
ried out with the use of the Autenrieth-Konigsberger 
colorimeter of Hellige. In this case less blood is neces- 
sary. Two c.c. are treated in a cylindrical centri- 
fuge tube with 8 c.c. of water and other manipulations 
as above. For the determination proper, 0.1 c.c. of 
10% sodium hydroxide are added to 2 c.c. of the 
picric acid filtrate in a small test tube. Simultaneously 
1 c.c. of the alkali is added to 20 c.c. of a saturated 
solution of picric acid containing 1.5 mg. creatinin to 
100 c.c. to serve as a standard for the wedge. At 
the end of 10 minutes the wedge is filled with the stand- 
ard, the cup with the unknown, and readings made. 
Although it is well to calibrate a wedge for a given 
instrument, the following formula, in which R repre- 
sents the colorimetric reading and 5 the dilution, will 
suffice : 

89-R X 0.0179 X 5 = mg. creatinin calculated per 100 c.c. of blood." 

References : Folin, O. : Jour. Biol. Chem., 1914, xvii, 
457; Benedict, S. R. : Jour. Biol. Chem., 1914, xxiii, 
183. 

The following methods for the determination of the 
uric acid in the blood are those given by Fine: 

"The blood is drawn from a vein into a 2 or 3 oz. 
wide mouth bottle containing about 10 drops of a 20% 
solution of potassium oxalate to prevent clotting. 
The amount of blood to be used for the determination 
varies with the concentration of uric acid. For a con- 
centration of 2 mgms. per hundred grams of blood, it is 
convenient to employ 25 c.c. of blood. This amount 
is pipetted into a casserole of 375 c.c. capacity and 



Tests of Kidney Function 141 

5 volumes of N/100 acetic acid * added. The mix- 
ture is heated first on a boiling water bath and then 
carefully over a flame with constant stirring, until a 
drop suspended from a stirring rod appears water 
clear. At this stage it is filtered through a folded 
hardened filter paper into a cylinder, the coagulum re- 
turned to the casserole, treated with 150 to 200 c.c. 
boiling water, and filtered directly into the cylinder 
containing the first filtrate. If practically water clear, 
the combined filtrates may at once be evaporated to a 
small volume after the addition of 2 c.c. of glacial 
acetic acid. If not clear, clarification may readily be 
brought about by boiling with approximately one-half 
teaspoonful of a thin suspension of common talc pow- 
der. It is usually necessary to pass this through a 
filter paper twice in order to remove any finely divided 
talc. When evaporated to 5 or 10 c.c, the material 
is transferred to a smaller casserole (150 c.c. capac- 
ity), employing a rubber tipped stirring rod and hot 
water to facilitate the removal of any material ad- 
hering to the sides of the casserole. The contents of 
the smaller casserole are now evaporated to about 1 
c.c, and transferred quantitatively to a 15 c.c. centri- 
fuge tube. This is then placed in a beaker containing 
boiling water to aid in flocking out of the suspended 
material. The clear fluid is obtained by centrifuging 
and decanting; the residue is shaken up with about 
5 c.c. boiling water and the clear supernatant fluid * 
obtained by centrifuging, and decanting into the main 
portion. In order to render the material entirely pro- 
tein-free, it is frequently necessary to return the fluid 
to the casserole, evaporate to 1 c.c. and repeat the 
process of removing the residual protein coagulum as 
already described. When completely protein-free, 
transfer to a 15 c.c. centrifuge tube, care being taken 



142 Manual of Vital Function Testvng Methods 

to keep the volume under 10 c.c. The uric acid is then 
separated as follows: 

"Add 2 drops of magnesia mixture,* 5 drops of 3 per 
cent, silver lactate solution, and enough strong am- 
monium hydroxide (15 to 20 drops) to dissolve the sil- 
ver chloride, after which the silver-magnesium-purine 
compound is observed to flock out. After standing a 
few minutes, it is centrifuged, the supernatant fluid 
decanted, and the last drop removed from the rim of 
the tube with filter paper. To the precipitate in the 
tip of the tube are then added one or two drops of 
glacial acetic acid and the compact mass thoroughly 
agitated. Finally 5 to 10 drops of strong hydrogen 
sulphide water are added, the mixture shaken, and 
placed in a boiling water bath for about 10 to 15 min- 
utes ; that is, until an excess of hydrogen sulphide is 
driven off and no brown coloration is observed after 
the addition of one or two drops of a 0.5 per cent, lead 
acetate solution. The tube is removed from the water 
bath, permitted to cool, and preparations made for de- 
veloping the color and comparing it with the standard. 

" Using the Duboscq Colorimeter. — One c.c. of a 
standard solution of uric acid, containing one mgm. 
uric acid per c.c.,* is placed in a 100 c.c. cylinder by 
means of an Ostwald-Folin pipette. To both the stand- 
ard and to the contents of the centrifuge tube, con- 
taining the uric acid to be determined, are added 2 c.c. 
of the Folin-Macallum phosphotungstic acid reagent.* 
To the standard cylinder are then added 20 c.c. of a 
saturated solution of sodium carbonate; the material 
in the centrifuge tube is then poured into a 50 c.c. 
cylinder and treated with a like amount of sodium car- 
bonate, the latter being first placed in the emptied cen- 
trifuge tube to wash into the cylinder any trace of uric 
acid. The standard is then made up to the 100 c.c. 



Tests of Kidney Function 



143 



mark and the unknown to the 50 c.c. mark. Both are 
shaken and the color at once compared in the colorim- 
eter. It is convenient to set the standard cup of the 
Duboscq at 10 mm. The concentration of uric acid 
per 100 c.c. can be calculated from the formula 

10 X V 

— , in which 10 represents the depth in millime- 

R X W 

ters of the standard, V represents the volume to which 
the unknown was diluted, R the reading in millimeters 
of the unknown, and W the weight or volume of blood 
employed for the analysis. It is desirable to develop 
the colors in such a manner that both the standard and 
the unknown will be as nearly as possible of the same 
intensity. The amount of blood used for the analysis 
and the volume to which the color is finally diluted are 
selected to meet this condition. The following will il- 
lustrate the relation between volume of blood used and 
final dilution of colors for bloods of various concen- 
trations of uric acid in order to obtain concentrations 
identical in intensity with the standard. 



Volume of Blood 


Uric Acid Concentration of Blood 


Final Dilution 


c.c. or grams 


mgms. per 100 c.c. 


c.c. 


25 
25 
25 
25 

10 
10 
10 
10 


1 
2 
3 
4 

1 
2 
3 
4 


25 

50 

75 

100 

10 
20 
30 
40 



"When using such small volumes as 10 c.c. of blood 
with only a normal concentration of uric acid, special 
care must be taken to keep the volume of the de-pro- 



144 Manual of Vital Function Testing Methods 

teinized fluid as low as 5 or 6 c.c. before precipitating 
the uric acid as the silver-magnesium-purine com- 
pound. In making up the colors of such final volumes 
as 10 to 50 c.c, the amount of Folin-Macallum reagent 
and sodium carbonate should be properly varied. Thus 
for a final volume of 25 c.c, 1 c.c. of the Folin-Macal- 
lum reagent and 10 c.c. of the saturated sodium carbon- 
ate is sufficient. It is of course not always possible 
in an initial examination to bring about the ideal con- 
ditions for color comparisons, since the concentration 
of the uric acid is not known ; and it may, therefore, 
be necessary to make a second determination in order 
to obtain a wholly satisfactory result. 

"Using the Hellige Colorimeter. — In comparing the 
colors a standard of double strength is employed for 

TABLE FOR THE ESTIMATION OF URIC ACID WITH THE HELLIGE 

COLORIMETER. 



Colori- 


Uric acid mgms. 


Colori- 


Uric acid mgms. 


Colori- 


Uric acid mgms 


metric 


per 100 c.c. 


metric 


per 100 c.c. 


metric 


per 100 c.c. 


reading 


dilution 


reading 


dilution 


reading 


dilution 


20 


1.67 


40 


1.28 


60 


0.88 


21 


1.65 


41 


1.26 


61 


0.86 


22 


1.63 


42 


1.24 


62 


0.84 


23 


1.61 


43 


1.22 


63 


0.82 


24 


1.59 


44 


1.20 


64 


0.81 


25 


1.57 


45 


1.18 


65 


0.79 


26 


1.55 


46 


1.16 


66 


0.77 


27 


1.53 


47 


1.14 


67 


0.75 


28 


1.51 


48 


1.12 


68 


0.73 


29 


1.49 


49 


1.10 


69 


0.71 


30 


1.48 


50 


1.08 


70 


0.69 


31 


1.46 


51 


1.06 


71 


0.67 


32 


1.44 


52 


1.04 


72 


0.65 


33 


1.42 


53 


1.02 


73 


0.63 


34 


1.40 


54 


1.00 


74 


0.61 


35 


1.38 


55 


0.98 


75 


0.59 


36 


1.36 


56 


0.96 


76 


0.57 


37 


1.34 


57 


0.94 


77 


0.55 


38 


1.32 


58 


0.92 


78 


0.53 


39 


1.30 


59 


0.90 


79 


0.51 



Note: Recently, Leitz, Inc., New York, N. Y., has put on the 
market several types of micro-colorimeters. These instruments 
require less blood, and give results accurate enough for clinical 
purposes. 



Tests of Kidney Function 145 

the wedge, e.g., the 1 mgm. is diluted to only 50 c.c. 
By consulting the accompanying table the uric acid 
corresponding to the colorimeter reading is obtained, 
from which the concentration of uric acid may be read- 
ily calculated. 

«# N/100 acetic acid is prepared by diluting 0.6 c.c. 
glacial acetic acid to one liter. 

"If at this point the suspended material does not set- 
tle readily, one or two drops of a very dilute solution 
of colloidal iron (One drop of a 5 per cent, solution 
diluted to 25 c.c.) may be added. 

"Magnesia mixture is prepared as follows : 35 grams 
MgS0 4 and 70 grams NH 4 C1 in 280 c.c. distilled 
water. Add 140 grams concentrated NH 4 OH and 
thoroughly mix. 

"A solution of 1 mgm. uric acid per c.c. is easily pre- 
pared by dissolving in a 100 c.c. beaker 100 mgms. 
Kahlbaum's uric acid in 50 c.c. of a 1 per cent, piper- 
azine solution. Transfer quantitatively to a 100 c.c. 
volumetric flask and make up to the 100 c.c. mark. 
One c.c. of such a standard solution contains one mgm. 
uric acid. It should be made up fresh at least every 
week. 

"The Folin-Macallum phosphotungstic acid reagent 
is prepared by boiling 100 grams Kahlbaum's sodium 
tungstate and 80 c.c. of 85 per cent, phosphoric acid 
in 750 c.c. of distilled water for two hours in a liter 
flask provided with a funnel to prevent evaporation. 
The reagent is finally made up to a volume of 1,000 
c.c. with distilled water." 



146 Manual of Vital Function Testmg Methods 



4* Estimation of Blood Coagulation Time as Test of 

Renal Function 

Bachrach-Tittinger Test. — In cases of renal insuf- 
ficiency, such cases as those in which it is claimed that 
ures for) the coagulation time has been found de- 
ures for 5 ) the coagulation time has been found de- 
layed. This delay is supposed to be connected with salt 
retention in the plasma. A rather large amount of 
blood is required according to the original technic of the 
originators (20 c.c). The test is not credited with 
much value. 

For method of estimating blood coagulation time 
see page 41. 

5. Cryoscopy of Blood as Test of Renal Function 

Cryoscopy of the Blood. — -This method has been 
employed by some investigators on the principle that 
under conditions of renal impermeability the waste 
products which fail to be eliminated in the urine will 
accumulate in the blood, thereby increasing the molecu- 
lar concentration. This means, of course, a lowering 
of its freezing point. 

The technic of estimating cryoscopy of the blood is 
not different from that applied to the urine, which 
has been already described (v. page 86). This method 
has not come into general use, however, and for this 
reason it will not be further considered here. 



III. STUDY OF THE ELIMINATION OF FOREIGN SUB- 
STANCES BY THE KIDNEY, AS CRITERION OF KIDNEY 
FUNCTION 

This category of tests may be divided into two parts : 



Tests of Kidney Function 147 

1. Miscellaneous Chemical Substances: 

a. Potassium iodide. 

b. Phloridzin. 

c. Hippuric acid. 

d. Lactose. 

2. Elimination of Dyes by the Kidney. 

a. Methylene blue. 

b. Indigo carmine. 

c. Phenolsulphonephthalein. 



1. Tests with Miscellaneous Chemical Substances 

a. The Potassium Iodide Test. — This was one of the 
first chemical substances applied to the estimation of 
renal function since it was suggested by Duckworth as 
long ago as 1867. 22 

Potassium iodide is rapidly absorbed from all the 
mucous membranes. 23 It is absorbed unchanged and 
appears quickly in the excretions. Only a few min- 
utes normally elapse before it can be demonstrated in 
the urine. According to the investigations of 
Quetsch, 24 Roux 25 and Studeni 26 it appears at any 
time from 9 to 18 minutes after doses of 1 to 3 grams 
have been swallowed. The greater part of the iodide 
ingested is excreted in the urine. Some, however, es- 
capes in the saliva and other secretions. 

Iodide is rapidly excreted, since 65-80% of the 
amount ingested is eliminated in 24 hours. Several 

22 St. Barthol. Hosp. Rep., 1867, III, 216. 
28 Cushing Pharmacology, 5 Ed., 1910, 510. 

24 Berl. klin. Wchnschr., 1884, XXI, 353. 

25 These de Paris, 1890, no. 248. 

26 Inaugural Dissertat., Zurich, 1897. 



148 Manual of Vital Function Testing Methods 

investigators have reported the exact time required 
for complete elimination to take place. According to 
Antem, 27 .5 gram requires 40 hours to be excreted, and 
Schlayer and Takayasu, 28 and Monakow 29 state that 
they found the same amount required 48 hours to 
eliminate. Schlayer concluded from his studies that 
the demonstration of iodide in the urine beyond 60 
hours after its administration may be considered de- 
layed, therefore a pathological excretion. 

Schlayer and his followers endeavored to fix as they 
did with sodium chloride the exact locus of elimination 
for iodide in the kidney. They believed that iodides are 
excreted by the tubular epithelium. They also con- 
tended that the elimination of iodide is not delayed 
in passive congestion (cardiac) while it is delayed 
in chronic tubular nephritis. These suppositions have 
neither of them been substantiated by subsequent in^ 
vestigations. 

Rowntree and Fitz in their experience with the iodide 
test have found it to vary markedly and they believe 
that the observation of excretion time of potassium 
iodide as a test of renal function is unreliable. 

Technic of Iodide Test. — .5 gm. (7% grains) of 
potassium iodide is given in solution by mouth in 
the morning on arising. The urine is collected at the 
end of 48 hours and every four hours thereafter and 
tested for iodide until a negative result is obtained. 

One of the simplest and best qualitative tests for 
iodide in the urine is that of Sandow. The test is 
made by taking 30 c.c. of urine, 2 c.c. of 2% solution 
of sodium nitrate and 2 c.c. of dilute sulphuric acid, 

27 Arch. f. Pathol, u. Pharmacol., 1902, XLVIII. 
M Deutsch. Arch. f. klin. Med., 1911, CI, 354. 
^Deutsch. Arch. f. klin. Med., CII, 248. 



Tests of Kidney Function 149 

adding chloroform and shaking. A purplish or violet 
color appears in the chloroform if iodide is present. 

b. The Phloridzin Test. — Von Mering 30 discovered 
the fact that the injection of the glucoside phloridzin 
into animals, produces a glycosuria without a hyper- 
glycemia, thus proving that the conversion is a vital 
act of the renal parenchyma. Achard and Delamare 31 
built upon this fact a method of testing the functional 
capacity of the kidney. 

Technic of Phloridzin Test. — .005 gm. of phloridzin 
in fresh aqueous solution is injected hypodermically. 
At 15-minute intervals the urine collected by catheter or 
voided spontaneously is examined for sugar. The 
maximum excretion takes place normally in an hour 
and disappears in 2 or 3 hours. 

c. The Hippuric Acid Test. — It has been long 
known that benzoic acid or benzoates are eliminated 
by the kidney as hippuric acid which is synthesized in 
the kidney from benzoic acid and glycocoll. Altho the 
fact has been used as a basis for testing kidney func- 
tion the results have been disappointing and the 
method has been abandoned. 

d. The Lactose Test. — Voit 32 was the first to demon- 
strate that lactose is eliminated by the healthy kidney 
following its subcutaneous or intravenous injection. 
De Bonis 33 claimed that the elimination takes place 
exclusively in the glomerulus. 

30 Centralbl. f. med. Wissensch., 1885, 531. 

31 Bull, et Mem. Soc. Med. d. Hop. de Paris, 1899, 379. 
82 Deut. Arch. f. klin. Med., 1897, LVII, 545. 
^Giorn. intern, d. scien. Med., 1907, XXIX, 446. 



150 Manual of Vital Function Testing Methods 

Lactose was suggested as a means of estimating renal 
functions in 1911 by Schlayer and Takayasu, 34 who 
with their co-workers studied the question of renal func- 
tion in experimental and clinical nephritis. These 
workers studied the elimination of lactose, potassium 
iodide, salt and water, dividing the nephritides into 
vascular and tubular varieties with subdivisions. 

Schlayer believed that the elimination of lactose be- 
ing exclusively, as he thought, a glomerular function 
could be taken as an index of the vascular functioning 
power of the kidney. Lactose being a foreign sub- 
stance that is not found in the organism would not 
be influenced in its elimination by extrarenal factors, 
and should therefore be an ideal criterion of glomerular 
function, any delay in its passage through the kidney 
indicating glomerular insufficiency. 

Following Nussbaum's 35 technic of obtaining in the 
frog an exclusively tubular secretion from the kidney 
by artificially excluding the glomerular secretion, 
Rowntree and Fitz 36 concluded that the tubular epithe- 
lium can secrete a certain amount of lactose, hence its 
elimination is not exclusively a function of the glomeru- 
lus. But they concluded also from their clinical experi- 
ments with lactose in the study of renal function in 
practice and also from some studies they have made 
in experimental passive congestion, that the mechanism 
of lactose excretion differs essentially from that of 
phthalein, salt, indigo carmin, etc., and that estima- 
tions of lactose excretion may be looked upon as a 
satisfactory index of the vascular, if not exclusively 
the glomerular function of the kidney. 

Technic of Lactose Test. — Two and five-tenths (2.5) 

"Deutsch. Arch. f. klin. Med., 1911. 

"Pfltiger's Arch. f. d. ges. Physiol., 1878, XVI, 179; XVII, 580. 

"Archives of Int. Med., 1913, XI, 25$. 



Tests of Kidney Function 151 

gms. of chemically pure lactose are dissolved in 25 c.c. 
of freshly distilled water, placed in small cotton stop- 
pered Erlenmeyer flasks and pasteurized for four 
hours for four successive days at 75 to 80° C. By this 
method the dose injected amounts to a little over 2 
gms. lactose in 20 c.c. of water. A fresh solution is 
used for each injection and a careful technic for in- 
travenous injection carried out. 

Following the injection there are usually no consti- 
tutional disturbances altho occasionally there may be 
some headache malaise or even chill followed by fever. 

The urine is collected four hours after the injec- 
tion and every hour or two hours after for twelve 
hours. Each specimen is tested for sugar by Nylander's 
reagent, using the same amount of urine, solution and 
length of time for boiling. Polarimetric readings may 
be made. 

The normal excretion time for this amount of lac- 
tose is four to six hours. The time required for secre- 
tion is the main point. Over six hours is delayed ex- 
cretion. 

(Nylander's reagent consists of Rochelle salts, 4 
gms. dissolved in 100 c.c. of 10% NaOH (sp. gr. 
1.015) ; warm and saturate with bismuth subnitrate 
(about two grams are necessary). When cool, filter 
and keep in a dark bottle. The solution remains perma- 
nent for years.) 

2. Elimination of Different Coloring Matters or Dyes 

as a Measure of Renal Fwnction. Urinary 

Chromoscopy 

There are three of these tests used at the present 
time, namely: 

1. The Methylene Blue Test. 



152 Manual of Vital Function Testing Methods 

2. The Indigo Carmin Test. 

3. The Phenolsulphonphthalein Test. 

Other coloring matters such as rosanilin, fuchsin, 
etc., have been suggested and employed at different 
times for estimating renal function, but with the ex- 
ception of the three named they appear to have fallen 
into disuse at the present time. 

Numbers 2 and 3 are most extensively employed, 
namely, indigo carmin which is used particularly in 
Europe and phenolsulphonphthalein which is by far 
the most popular colorimetric test in this country. 

Rosanilin (sodium trisulphate) was introduced by 
Lepine. 37 One c.c. of a 1% solution is injected hypo- 
dermically. The dye appears normally in the urine 
in less than half an hour, total elimination requiring 
twenty-four hours. The test has never attained wide 
use, probably because of the greater success attending 
the use of phenolsulphonphthalein according to the 
method of Rowntree and Geraghty (q. v.). 

a. The Methylene Blue Test. — The introduction 
of methylene blue as a test for renal function is 
credited to A chard and Castaigne. 38 These authors 
gave the drug intramuscularly, using 1 c.c. of a 5% 
solution. Later Czyhlarz and Donoth 39 recommend- 
ed it by mouth in ^4 grain dose. The drug is rapidly 
eliminated in the urine, appearing therein in about 
fifteen minutes as a colorless chromogen, as dem- 
onstrated by Voisin, 40 which may be shown by boiling 
the urine after addition of acetic acid. Normally the 
color itself appears in the urine in half an hour. The 

87 Lyon M6dical, 1898. 

88 Bull, et Mem. Soc. M6d. d. h6p. de Paris, April, 1897, 637. 
88 Wien. klin. Wchnschr., XXIV, 1899, 649. 

40 Gaz. Hebd. MeU, 1897, 493. 



Tests of Kidney Function 153 

excretion of both forms continues for 36-48 hours, but 
even in health the time may be very much prolonged. 

The authors of the test recommended that the time 
of first appearance, time of maximum intensity of 
excretion and time required for total excretion should 
be noted. 

Diminished renal permeability was thought to delay 
or prolong all three. Various observers confirmed 
these suppositions. In some cases of chronic inter- 
stitial nephritis the elimination was found to be pro- 
longed for two weeks. Various modifications of the 
type of elimination under pathological conditions were 
described, consisting of remittances or intermittances of 
excretion. 

Later observers noted that elimination is not delayed 
in all forms of kidney disease and that the elimination 
under certain circumstances might be normal or even 
accelerated. 

Attempts to measure quantitatively the elimination 
of methylene blue were made, one of which described 
by Rowntree and Geraghty will be mentioned under 
technic. 

The methylene blue test was later applied to diag- 
nosis in surgical diseases of the genitourinary tract 
and was at one time considered the best test available 
for estimating the functional capacity of one or both 
kidneys. Walker showed that the elimination is re- 
tarded in lower urinary tract obstructions as in cer- 
tain types of prostatic hypertrophy. Casper made 
similar observations. 

Methylene blue produces some pain when given sub- 
cutaneously and occasionally when given intramuscu- 
larly. This of course is a drawback though perhaps 
not a serious one. Another and greater drawback is its 
prolonged elimination necessitating a large number of 



154 Manual of Vital Function Testing Methods 

urine examinations. A third objection is the difficulty 
of accurate colorimetric estimations. 

Finally, the methylene blue test is imperfect in that 
part of the substance is converted into a colorless 
chromogen in the body secreted as a leucobase and 
therefore does not contribute to the color results in 
the urine. Only 50% of the drug is normally passed 
out in the urine. 

It has not been demonstrated with certainty in what 
part of the kidney the elimination of methylene blue 
takes place. 

In disease of the tubular epithelium that is in the 
chronic parenchymatous nephritis, methylene blue is 
quickly and completely eliminated ; in interstitial neph- 
ritis, the elimination is delayed. 

The duration of elimination is diminished in paren- 
chymatous and increased in interstitial nephritis. A 
cyclic, polycyclic or intermittent elimination of the 
coloring matter has been said to indicate several dif- 
ferent conditions: disturbance of kidney innervation, 
hepatic insufficiency, interstitial nephritis and pyo- 
hydronephrosis. 

Up to the time of the advent of the phenolsul- 
phonphthalein test, the methylene blue test was the 
most extensively used method of determining renal per- 
meability. At the present time, certainly in America, 
the Rowntree-Geraghty test has quite superseded it. 

Technic of Methylene Blue Test. — After urination 
1 c.c. of a 5% solution of methylene blue is injected 
intramuscularly. A sterile catheter may be introduced 
into the bladder or the patient may empty the bladder 
in 15 minutes if possible to determine the presence of 
the leucobase or chromogen. This is done by boiling 
the specimen and adding a few drops of acetic acid. 
A greenish color denotes the presence of the chromogen. 



Tests of Kidney Function 155 

At the end of half an hour the bladder should be 
emptied spontaneously or by catheter and the urine 
examined for color. A greenish blue color denotes the 
presence of the dye. 

As above mentioned, the time of appearance, time of 
maximum intensity and time required for total elimina- 
tion (disappearance of color) should be noted. 

Quantitative Estimation. — Before administration of 
the drug the urine is collected for some time and kept. 
The methylene blue is given in the usual manner, the 
urine collected for as long a time as necessary, all 
chromogen being converted into dye. An equal quan- 
tity of urine previously collected is taken, to which 
is added from a burette, drop by drop, a sufficient 
quantity of a solution of methylene blue of known 
strength until the colors are alike. Compare against 
a white background. From the quantity of methylene 
blue used, the amount of coloring matter may be esti- 
mated. 

b. The Indigo Carmine Test. — Volcker- Joseph 
Test. 41 — The dye was first used by Heidenhain in his 
famous investigations into the physiology of the kid- 
ney. He believed that this substance is eliminated ex- 
clusively by the epithelial cells of the convoluted 
tubules. 

Indigo carmin possesses the advantages over methy- 
lene blue that the quantity required for the test is 
completely eliminated through the kidney and that no 
leucoderivative is formed in the tissues. 

After the intramuscular injection of .08 gm. to .16 
gm. of indigo carmin, elimination begins in 6 to 8 min- 
utes if the kidney is normal. The intensity of the color 
will give some idea of the concentrating power of the 
41 Munch, med. Wchnschr., 1903, 2081. 



156 Manual of Vital Function Testing Methods 

kidney, that is to say, the water resorbing power of 
the tubules, and consequently, its capacity to produce 
a urine of high molecular concentration. 

A polycyclic or intermittent elimination is said by 
Blum to indicate intermittent hydronephrosis. In 
strongly alkaline urine the dye may be discolorized. 
In parenchymatous nephritis, the elimination of indigo 
carmin may be normal. In interstitial nephritis the 
elimination begins later than normal, is diminished in 
quantity and much prolonged. The delayed elimination 
indicates a diminished reaction power of the kidney, the 
diminished elimination a loss of water resorbing power, 
a hyposthenuria, a loss of the concentrating function 
of the organ, while the long duration of elimination indi- 
cates a general loss of secreting power as always accom- 
panies the sclerotic kidney. 

The indigo carmin test has been quite extensively 
used, especially in Europe, in testing the functional 
capacity of the single kidney by ureteral catheteriza- 
tion and in general functional testing of the kidney. It 
is considered superior to methylene blue because of 
more rapid elimination. But in this respect, as in 
others, it is inferior to phenolsulphonephthalein, which 
substance, since its introduction for this purpose by 
Rowntree and Geraghty, has become the most exten- 
sively used chromoscopic test, at least in this country. 

Rowntree and Geraghty consider the indigo carmin 
test of more value than the methylene blue test because 
of its Inore rapid appearance in the urine, but that it 
is less adapted to functional work than phenolsul- 
phonephthalein. This opinion is now shared by most 
other workers in this field. 

Technic of Indigo Carmin Test. — A 4% solution is 
made. Twenty c.c. of this solution are injected into the 
muscles usually of the gluteal region. There is some 



Tests of Kidney Function 157 

pain produced by the injection. In 10 to 15 minutes 
the urine is collected. In normal persons it is tinged 
greenish blue in this time. Excretion is usually com- 
plete in 24 hours, but practically the greater portion 
escapes in 12 hours. The color of the dye in the urine 
does not lend itself well to colorimetric estimation. In 
this respect it resembles methylene blue. Purulent 
urine decolorizes indigo carmin. It is estimated that 
not more than 25% of the amount injected finds its 
way out through the kidneys. The fate of the balance is 
unknown. 

c. The Phenolsulphonephthalein Test. Rowntree- 
Geraghty Test {The Red Test).— The phenolsul- 
phonephthalein test of kidney function had its origin in 
the pharmacological researches of Abel and Rowntree, 
upon the phthaleins generally. Of all the phthaleins 
studied by these investigators, phenolsulphonephthalein 
stood out in striking contrast with all others because 
of the fact that it is almost exclusively eliminated by 
the kidney. 

This fact suggested its use as a test of renal func- 
tion to Rowntree and Geraghty and their first com- 
munication upon this subject appeared in July, 1910. 42 

Phenolsulphonephthalein has the following formula: 

C 6 H 4 OH 
C 6 H 4 OH 



C 6 H 4 



S0 2 

Jour. Pharmacol, and Exp. Therap., I, 1910, 579. 




158 Manual of Vital Function Testing Methods 

It was first made by Remsen. 43 The substance is a 
red crystalline powder, partly soluble in water, the 
solution when alkaline being red, becoming more purple 
as the alkalinity is increased. 

Abel and Rowntree in their pharmacological inves- 
tigations of the phthalein group showed that the sub- 
stance appears in the urine after administration by 
mouth in one to one and a half hours and after sub- 
cutaneous injection in about 10 minutes. They found 
that after fair-sized doses ( 1 gm. ) the drug appears 
in the bile, is passed into the intestine, there reabsorbed, 
and, except for a mere trace, is excreted wholly by the 
urine. 

Phenolsulphonephthalein is practically non-toxic. 
When a dose of .006 gm. is injected subcutaneously, 
40-60% of this quantity is recovered in the urine dur- 
ing the first hour after injection. From 15-25% more 
is recovered in the second hour, making a total excretion 
for the first two hours following the injection of 
60-85%. 

Normally when the urinary flow is free, the dye ap- 
pears in the urine in 5 to 10 minutes after injection. 
The maximum excretion appears in 15 to 20 minutes. 
This density of excretion continues an hour to an hour 
and a half. The elimination then begins to diminish. 
At the end of the first hour the pink color on addition 
of alkali is slight, and after the expiration of two hours 
excretion is practically complete. 

In acute nephritis, Rowntree and Geraghty 44 found 
a diminished excretion of phthalein in two out of three 
cases. In parenchymatous nephritis there was a marked 
diminution of excretion in seven out of eight cases. In 
chronic interstitial nephritis a low output was encoun- 

"Amer. Chem. Jour., VI, 280. 

44 Jour. Phar. and Exp. Ther., I, 1910, 656. 



Tests of Kidney Function 159 

tered in all the cases experimented upon, 10 in number. 

These results concerning the lowered excretion of 
phenolsulphonephthalein in the nephritides have as a 
general thing been entirely corroborated in subsequent 
investigations by many different observers. 

In their first researches Rowntree and Geraghty 
made over two hundred functional tests in one hundred 
and fifty persons. To them the phenolsulphonephtha- 
lein seemed to possess advantages over all other func- 
tional tests, these advantages consisting chiefly in the 
following points : 

1. The early appearance of the dye in the urine 
and its rapid and complete elimination by the kidney. 

2. The accuracy and simplicity of quantitative esti- 
mation of the drug in the urine. 

They showed by these researches that the permeabil- 
ity of the kidney for phenolsulphonephthalein is de- 
creased in both parenchymatous and interstitial nephri- 
tis, the decrease being most marked in the latter form. 

Further than this they showed that the test is of 
value to the surgeon in determining the true condition 
of the kidney, in cases with prostatic obstruction. In 
such cases the authors believed the phenolsulphone- 
phthalein test to be of greater service than urinalysis or 
nitrogen estimations and that the use of the test in 
cases of obstruction in the lower urinary tract prior 
to operations would disclose the necessity of prelimi- 
nary treatment. Finally they pointed out that the 
test lends itself and is well adapted to unilateral esti- 
mations of the functions of the separate organs in con- 
junction with ureteral catheterization. 

In surgical cases with urinary obstruction, the 
authors contended that when the phthalein excretion 
is delayed beyond twenty-five minutes and the output 
for the first hour is below 20% the operation may prof- 



160 Manual of Vital Function Testing Methods 

itably be postponed until treatment by drainage has 
improved conditions, such improvement being shown by 
an increase in the elimination of phthalein at a subse- 
quent time. 

Technic of Phenolsulphone phthalein Test. — Twenty 
minutes to half an hour before giving the test the 
patient is given 200 to 400 c.c. of water to insure 
diuresis. The bladder is catheterized or completely 
emptied. The time being noted, 1 c.c. of a solution of 
the drug is injected into the lumbar muscles. The solu- 
tion is prepared as follows: .6 gm. phenolsulphone- 

phthalein and .84 c.c. - NaOH are added to .75% NaCl 

solution. Add two or three drops of - NaOH. The 

color becomes Bordeaux red and the solution is non- 
irritant. 

The urine is passed into a test tube containing a drop 
of 25% NaOH and the time of appearance of the first 
pinkish color noted. 

If there is no urinary obstruction the catheter is 
not necessary after the appearance of the color, and 
the patient may then retain the urine and urinate at 
the end of one hour in one receptacle and again at the 
end of the second hour in another. 

A rough estimate of the time of the appearance of 
the drug in the urine may be gained by having the 
patient urinate, frequently, a small amount without 
the catheter. In prostate cases it seems better to keep 
a catheter in situ. If this is done the catheter may 
be corked and this is removed at the end of the first 
and second hours. 

Each sample of urine is measured. Twenty-five per 
cent. sol. NaOH is added to make the color maximum. 



Tests of Kidney Function 161 

The urine is usually yellow or orange and becomes deep 
purple on addition of the alkali. The solution is put in 
a liter flask and diluted with distilled water to make a 
quart. This is thoroughly mixed and a portion is fil- 
tered and compared with a standard in a colorimeter. 45 
The standard solution consists of .003 gm. phenolsul- 
phonephthalein (^ c.c. of solution used for injection) 
diluted to 1 liter and made alkaline with a few drops 
of 25% NaOH. The test solution retains its fine 
purplish color for a week or more. 

The colorimeter contains a wedge-shaped cup which 
is filled with the standard solution. The rectangular 
cup is filled with the solution to be tested. The wedge- 
shaped cup is manipulated by a screw until the color 
fields are identical. The percentage is read off on the 
indicator scale. 

Technic of the Phenolsulphonephthalein Test as Ap- 
plied to Estimation of the Function of the Individual 
Kidney. — Twenty minutes previous to the application 
of the test the patient is given 600 to 800 c.c. of water 
to provide a free flow of urine. The ureters are 
catheterized, a special catheter being recommended, 
namely, the flute end catheter of Albarran No. 6 or 
No. 7. The catheters are passed four inches into the 
ureters. The cystoscope is withdrawn, leaving the 
catheters in situ. A small urethral catheter is passed 
into the bladder to empty that organ and detect later 
leakage. The other details of the test are similar to 
those of the ordinary technic (q. v.). 

In September, 1911, Geraghty and Rowntree 46 made 

45 The colorimeter used by Rowntree and Geraghty is a modi- 
fication of the Autenrieth-Konigsberger instrument. This can be 
obtained from Hynson and Westcott, Balto., Md., who also sup- 
ply convenient ampoules containing .006 gm. in each c.c. of phe- 
nolsulphonphthalein. 

46 Jour. Amer. Med. Assn., 1911, LVII, 815. 



162 Manual of Vital Function Testing Methods 

a report of their previous experience with the sul- 
phonephthalein test and reiterated their first opinion 
that the test devised by them appeared to possess dis- 
tinct advantages over all other methods of examining 
renal function. The reasons upon which this opinion 
was based have been given above. 

They concluded that the sulphonephthalein test will 
enable the clinician to determine quantitatively the 
amount of functional derangement of the kidneys in 
his nephritis cases, whether of the acute or chronic 
type. That in cardiorenal cases the test will show 
exactly to what extent the kidney is involved. That 
the test is of special value in the diagnosis of uremia 
from other conditions which may simulate it and also 
to foretell in many cases an impending uremia before 
the appearance of indubitable clinical signs. 

The authors reiterated their confidence in the value 
of this test in cases of urinary obstruction, it being 
in their judgment superior under these circumstances 
to measuring the urinary quantity, and to urea or total 
nitrogen estimations. 

In many surgical cases studied by them in the genito- 
urinary clinic of Young at Johns Hopkins, they found 
that separate studies of unilateral kidney function re- 
vealed more accurate and dependable information than 
any other method of examination. 

In a third and very complete report of their phenol- 
sulphonephthalein test of kidney function published in 
1912, Rowntree and Geraghty studied carefully the in- 
fluence on the rate of excretion, of the various methods 
of administration, subcutaneous, intramuscular and in- 
travenous. They concluded from their researches that 
intramuscular injection into the lumbar region is the 
method of choice. 

Studying the influence of various diuretics upon the 



Tests of Kidney Function 163 

excretion of sulphonephthalein the authors found that 
while under the conditions of animal experimentation, 
some slight increased activity was caused by certain 
stimulating diuretics like caffein, yet clinically these 
substances do not affect the phthalein output. 

The route of phthalein through the kidney was in- 
vestigated and it was demonstrated that the drug is 
excreted chiefly by the uriniferous tubules and the 
smaller remainder by the glomerulus. 

In nephritis of all types the output of phthalein 
was found diminished, the diminution of excretion be- 
ing apparently in proportion to the amount of damage 
to the kidney structure. So that the test is of consider- 
able value from a diagnostic and prognostic standpoint 
since the amount of functional incapacity is revealed. 

In those cases in which the heart and kidney are 
both affected (the so-called cardiorenal cases) the test 
was found useful in determining just what proportion 
of the trouble could be referred to the heart disease and 
what to the renal lesions. 

In uremia the test proved in the hands of its authors 
of value in differentiating uremia from conditions sim- 
ulating it. In certain cases, when no clinical evidence 
of the imminence of uremia was present, a very low 
phthalein output frequently enabled the authors to fore- 
see the danger. 

From a surgical standpoint the earlier opinions held 
by Rowntree and Geraghty as to the utility of the test 
in cases of urinary obstruction were completely cor- 
roborated by their subsequent work. 

According to them the test is more dependable than 
estimation of urinary output, total solids, urea or total 
nitrogen, in indicating to the surgeon the propriety of 
operation or the institution of preliminary treatment, 
in contemplated nephrectomy and prostatectomy. 



164 Manual of Vital Function Testing Methods 

Finally their studies tended to show that no other 
test is so adaptable to the examination of unilateral 
kidney function to determine the relative amount of 
work performed by each organ separately. 

The medical and surgical aspects of the phthalein 
test will be further developed later on under the general 
summary of renal function tests in their medical and 
surgical aspects, (v.i.) 

Since the introduction of the phenols ulphonephtha- 
lein test for kidney function in July, 1910, a very con- 
siderable literature upon the subject has appeared. It 
is very striking how few are the criticisms and how 
numerous are the encomiums which have been passed 
upon the test of Rowntree and Geraghty. It might al- 
most be said that, in this country at least, the opinion 
of those who have used it is unanimously favorable and 
tends to corroborate in every particular the claims 
which were advanced for it by its authors. 

Clinical and experimental corroboration of the sul- 
phonphthalein test have been given by the publications 
of Austin and Eisenbrey, 47 Boyd, 48 Cooke, 49 Sehrt, 50 
Lance, 51 Sanford, 52 Behrenroth, 53 Frank, 53 Bonn, 54 
Erne, 55 Mouriquand, 56 Lohnstein, 57 Frothingham, 
Fitz, Folin, Denis, 58 Christian, Janeway, Cabot, 



47 Jour. Exper. Med., 1911, XIV, 367; 462. 

48 Jour. Amer. Med. Assn., 1912, LVIII, 620. 

49 Providence Med. Jour., 1912, XIII, 118. 
B0 Centralbl. f. Ch., 1912, XXXIX, 2, 1121. 

51 Gaz. d. hop. de Par., 1912, LXXXV, 32. 

62 Cleveland Med. Jour., 1912, XI, 763. 

53 Ztsch. f. Exp. Pathol, u. Therap., 1913, XIII, 72. 

64 Jour. Ind. State Med. Assn., 1913, VI, 154. 

55 Munch, med. Wchnschr., 1913, LX, 510. 

56 Lyon Medicale, 1913, CXXL, 299. 

57 Allg. Med. Centr. Gtz., 1913, LXXXII, 591. 
58 Arch. Int. Med., 1913, vols. XI-XII; also Jour. Exper. Med., 
1911, XIV, 366. 



Tests of Kidney Function 165 

• 
Dock, 59 Snowden, Thayer, 59a and many others. 

While many of these reports are extremely illuminat- 
ing and important, it cannot be said that they have 
added anything noteworthy to the test itself, or to its 
indications, which fact is a strong testimony of the thor- 
oughness and care with which the work had originally 
been performed by Rowntree and Geraghty before its 
publication. 

From the standpoint of pure experimental corrobora- 
tion, the work of Austin and Eisenbrey should be noted. 
These authors in 1911 studied the elimination of phe- 
nolsulphonephthalein as compared with the elimination 
of nitrogen and chlorides, in experimental nephritis in 
dogs set up by administering uranium, cantharidin, and 
potassium bichromate. They concluded, among other 
things, as a result of their researches, that a marked 
and early decrease in the elimination of phenolsulpho- 
nephthalein takes place in the experimental nephritides 
and that the phthalein test is the better indicator of 
renal function under the circumstances than total ni- 
trogen or chloride elimination, which latter are more 
irregular and inconstant. 

Other investigators have experimented along the same 
line, studying the phthalein elimination in experimental 
nephritis and their results have tended to corroborate 
the earlier researches. Perhaps the most recent con- 
tribution to this phase of the subject is that of Potter 
and Bell. 60 These authors have studied the phthalein 
elimination, also that of lactose and potassium iodide 
in experimental tartrate nephritis in rabbits. 

It may be recalled that Underhill, Wells and Gold- 

schmidt 61 discovered that the injection of racemic tar- 

69 Tr. Cong. Amer. Phys. & Surg., 1913, IX, 45. 
6Q aAmer. Journ. Med. Sc, 1914, CXLVIII, 781. 
60 Amer. Jour. Med. Sci., CXLIX, 1915, 236. 
91 Jour. Exper. Med., 1913, XVIII, 322. 



166 Manual of Vital Function Testing Methods 

taric acid into rabbits produces a type of acute nephri- 
tis in which the great majority of the convoluting tu- 
bules become necrotic and the rest are fatty and gran- 
ular. The glomeruli may be anatomically intact. In 
kidneys of this type it has been found that the excretion 
of phenolsulphonephthalein, likewise indigo carmin and 
methylene blue, is completely suppressed. The excre- 
tion time of lactose is over twice as long as normal, 
while that of potassium iodide is four times as long as 
normal, but both lactose and potassium iodide are ex- 
creted by this type of kidney. Potter and Bell suggest 
that their results appear to show that phthalein, indigo 
carmin and methylene blue are excreted exclusively by 
the tubules, while potassium iodide and lactose are 
at least partly excreted by the glomeruli. 

In experimental chronic passive congestion of the 
kidney in animals, produced by compression of the vena 
cava and renal veins, Rowntree, Fitz, and Geraghty 62 
found that the functional capacity of the kidney as 
judged by the phthalein output is reduced. The reduc- 
tion, however, only occurs as the degree of passive 
congestion becomes marked. 

Goldsborough and Ainley in 1910 63 studied the renal 
function in pregnancy and the puerperium by means of 
sulphonephthalein, and concluded that even normal fe- 
males in pregnancy eliminate less phthalein than non- 
pregnant. In the ninth month the power of elimination 
may be very low. The exact meaning of these facts is 
not known. This result was confirmed by Roth, 64 
who also claimed that women with diseases of the genital 
tract were unsuitable for the test. These investigations 
of Goldsborough, Ainley and Roth have not been subse- 

c Arch, of Int. Med., 1913, XI, 121. 
68 Journ. Amer. Med. Assn., 1910, LV, 2058. 
M Berl. klin. Wchnschr., 1913, L, 1609. 



Tests of Kidney Function 167 

quently developed. In this connection it may be men- 
tioned that Pepper and Austin 65 reported in 1913 that 
occasionally cases of parenchymatous nephritis will 
show a quite prompt and fairly normal elimination of 
phthalein. In one of their cases there was a phthalein 
output of 67% for one hour, strongly suggesting 
hyperpermeability. Baetjer has also encountered sim- 
ilar cases. Such cases do not appear to represent the 
rule, however, and just what meaning is to be attached 
to these facts is at present unexplained. 

A few suggestions for slight variations of technic in 
the test have been published but none of them appears 
to have been generally adopted. They are few in num- 
ber and the most important may be given. 

Fromme and Rubner 66 in 1912 suggested that the 
phthalein should always be given hypodermically and 
that the observation period should be extended to three 
hours. Keyes and Stevens 67 also recommend hypoder- 
mic injection when the ureters are to be catheterized. 
Bonn, 68 as a result of his experience, thought that the 
time of appearance of the dye in the urine is not of 
much importance except to determine the time for per- 
centage estimation. He recommended the intravenous 
injection of the phthalein when the ureters are to be 
catheterized. He does not believe that the test will 
inform the surgeon when the patient can be operated on 
safely. He, however, states that, in his belief, the test 
is the best one yet devised for studying the renal func- 
tion. 

Fanz 69 suggests to add a quantity of the patient's 
urine obtained just before injecting the indicator, equal 

65 Amer. Journ. Med. Sc, 1913 n. s. CXLV, 254. 
"Berl. klin. Wehnschr., 1912, XLIX, 1889. 
67 N. Y. Med. Jour., 1912, XCV, 1134. 
" Indiana State Med. Assn. Jour., 1913, VI, 154. 
69 N. Y. Med. Jour., 1915, C, 1193. 



168 Manual of Vital Function Testing Methods 

in amount to the first hour's urinary output after the 
injection. The standard solution now will have ap- 
proximately the same amount of urinary salts as the 
specimen solution, and the standard and urinary solu- 
tion will equal each other in opaqueness and yellowish 
tint, making color comparison easy. To make up the 
standard solution, he uses 1 c.c. of the contents of an 
ampoule * of the phenolsulphonephthalein, adds the pa- 
tient's urine (obtained before injecting the indicator) 
in amount to equal the first hour's urinary output after 
appearance of the drug. This mixture is alkalinized 
with 25 c.c. of 10% solution of potassium hydroxide, 
filtered, and sufficient distilled water is added to make 
1000 c.c. This is the standard and contains 100% of 
the indicator in 1000 c.c. 

The first hour's urinary output, after injection of 
2 c.c. phenolsulphonephthalein, is now alkalinized with 
25 c.c. of 10% potassium hydroxide and filtered. To 
this is added distilled water to make 1000 c.c. This is 
the test specimen. By diluting a unit of the standard, 
say 50-100 or 200 c.c, with distilled water until it 
matches the 1000 c.c. solution of the first hour's urinary 
output, the direct percentage of the indicator in the 
first hour's specimen can easily be estimated. Say 100 
c.c. of the standard had to be diluted up to 500 c.c. 
before it matched the first hour's specimen dilution, then 
the standard would be five times as strong as the speci- 
men, or the specimen would contain 20% of phenolsul- 
phonephthalein. The second hour's output of phenol- 
sulphonephthalein is estimated precisely like the first. 

As a matter of fact it does not appear that any 
modifications of the original test method as described 
by Rowntree and Geraghty has contributed materially 
to its simplification or improvement, and for this reason 

* Marketed by Hynson and Westcott. 



Tests of Kidney Function 169 

the original method is usually followed. 

Thayer and Snowden 70 have recently attempted to 
compare their results obtained by the test with the 
anatomical changes found in the kidneys at autopsy. 
They conclude, as the result of their quite extensive 
investigations, as follows : 

In severe chronic nephritis there is always a low 
phthalein output. This rule, in their experience, has 
absolutely no exception. The phthalein output in cases 
of chronic nephritis diminishes steadily, according to 
them, until the terminal uremia, when it approaches 
zero, just prior to death. 

In the passive renal congestion of heart disease, there 
is often a reduction in the elimination of phthalein, 
especially when the amount of decompensation of the 
heart is considerable. When these symptoms become 
ameliorated, the phthalein output increases. 

If passive congestion of the kidney from heart disease 
is accompanied by concomitant chronic nephritis the 
output of phthalein is lower than in cases of uncom- 
plicated congestion. 

In one case of acute nephritis and one of amylosis 
the phthalein output was reduced. 

In acute infectious diseases, during which cloudy 
swelling of the renal parenchyma occurred, there was 
found a considerable reduction of phthalein output. 

From this study Thayer and Snowden concluded 
that the phenolsulphonephthalein test of Rowntree and 
Geraghty is a procedure of great diagnostic and prog- 
nostic value, especially in the study of chronic neph- 
ritis. 

70 Amer. Jour. Med. Sci., 1914, CXLVIII, ' 781. 



170 Manual of Vital Function Testing Methods 



GENERAL SUMMARY OF THE APPLICATION OF RENAL 
FUNCTION TESTS 

This subject may be divided into two parts : 1, Renal 
Function Tests and Their Medical Application. 2. 
Renal Function Tests and Their Use in Surgery. 

1. Medical Application. — A decade ago the burning 
question in renal pathology was whether the varying 
clinical findings in chronic nephritis could be divided 
into classes and each class correlated with certain defi- 
nite histopathological findings in a kidney post mortem. 
Although no absolute answer to the question was 
reached, there is no doubt some progress was made. 
During the past decade, in line with the general depar- 
ture of interest somewhat away from the anatomical 
toward the functional view in pathology, a serious at- 
tempt was made to divide the clinical symptomatology 
of nephritis into groups ; to correlate these groups with 
certain definite types of renal involvement. Although 
this worthy attempt has not been entirely successful any 
more than its anatomical prototype which preceded it, 
some important facts have been learned which are of 
value from a practical as well as a theoretical stand- 
point. The method by which these advances have been 
gained is none other than the application of functional 
tests to a study of the different phases of renal activity. 

Different portions of the glomerulo-tubular structure 
of the kidney have been supposed to possess selective 
secretory activities. It cannot be said that these selec- 
tive activities are yet understood, so that at the present 
time there is no such thing as an exact topical diagnosis 
of the kidney functions. 

Nor can it be said in any case that the results of the 
most complete and comprehensive functional examina- 



Tests of Kidney Function 171 

tion will reveal with any certainty the anatomical 
changes which are present in the kidney. Certainly 
they will not reveal the extent to which the vascular, 
glomerular or tubular structures are involved in a given 
case, and will shed but little light upon the relative 
proportions of the changes. 

Our chief clinical terms in renal pathology still re- 
main as they were in the older tradition ; we still speak 
currently of acute nephritis, chronic parenchymatous 
nephritis and chronic interstitial nephritis, but we are 
not surprised when the autopsy shows the extreme rar- 
ity of these arbitrary types and presents us with patho- 
logical pictures of such great complexity that it is no 
wonder that the intricate problem is not to be solved by 
the most skillful and painstaking ante-mortem exami- 
nation. 

Great hopes were aroused some years ago in this 
direction when it was discovered that experimental in- 
flammation of the kidney may be set up in animals by 
the use of certain poisons 71 which make it possible to 
submit some of these difficult problems in renal pathol- 
ogy to experimental investigation. Although little has 
come of this work so far, it appears to be founded 
upon rational and scientific principles and the work 
must be enthusiastically encouraged to go on. 

Schlayer, Hedinger, and Takayasu, in the Romberg 
Clinic at Tubingen, have applied themselves assiduously 
to working out the problems of pathological kidney 
function from an experimental standpoint. In this 
country the purely experimental method has yielded 
interesting results in the hands of Rowntree, Fitz, 
Geraghty, Christian, O'Hare, Folin, Karsner, Denis, 
Frothingham, Austin, Eisenbrey, Potter, Bell, and 

T1 Uranium, chromates, mercuric chloride, cantharidin, tartrates, 
etc. 



172 Manual of Vital Function Testing Methods 

others. For an interesting contribution dealing with 
the relation of functional tests to pathological diag- 
nosis, the reader is referred to an article by Christian, 72 
to which an excellent bibliography is appended. The 
author of this review very justly concludes that tests 
of renal function are quite capable of demonstrating 
the bare fact (the important fact indeed) that the kid- 
neys are diseased but are quite unable to disclose the 
exact type of pathological lesion of the kidney, which 
exists in any given case. 

While no functional test is capable of disclosing the 
nature or location of the pathological lesion, it may be 
perfectly capable of disclosing the inability of the kid- 
ney to perform a given function or set of functions, 
such, for example, as the elimination of water, salt, 
urea or some foreign substance such as lactose or 
phthalein. Such an inability on the part of the kidney 
will indicate a depreciation of its functional power if 
the test is properly carried out, and this particular 
information may be important in prognosis and treat- 
ment although we shall be unable with certainty to point 
to the seat of the disturbance in the kidney or identify 
with exactitude the nature of the underlying patho- 
logical lesion. 

From a medical standpoint renal function tests are 
most important in defining the state of kidney activity 
in the acute and chronic nephritides, orthostatic and 
other albuminurias, arteriosclerosis, uremia, and myo- 
cardial insufficiencies. 

In some medical clinics renal function tests are ap- 
plied as a matter of routine to all these classes of cases. 
While they do not in themselves make the diagnosis or 
settle the prognosis it is contended, very properly per- 
haps, that they will occasionally reveal an unsuspected 
72 Trans. Cong. Amer. Phys. and Surg., 1913, IX, 1. 



Tests of Kidney Function 173 

latent deterioration of kidney function, just as routine 
blood examinations may reveal an unsuspected leukemia. 

Renal functional tests will be of prognostic value be- 
cause they will often serve to show whether the disease 
is stationary, progressing or recovering. Of course it 
hardly needs to be said that renal function tests will 
always be carried out in the medical clinic in conjunc- 
tion with the clinical study of the patient. A progres- 
sive lowering of the kidney function in chronic nephri- 
tis may indicate impending uremia. 

The question of the prognostic value of renal func- 
tional tests has been made the theme of a very complete 
and excellent article by Rowntree. 73 According to this 
investigator the prognostic value of renal functional 
studies is as great in medical as it is in surgical cases. 
In acute nephritis, the prognosis depends upon the eti- 
ology more than the result of functional tests. In mild 
chronic nephritis with slight albuminuria and cj^lindru- 
ria, slight hyperpiesis, moderate arteriosclerosis and 
hypertrophy, the tests may show how great the func- 
tional deterioration may be, and the regular repetition 
of the tests will show whether the disease is progressing 
or not. In advanced nephritis also, the proper func- 
tional tests will disclose the severity of the disease and 
the imminence of uremia. Cases of clinically well- 
marked nephritis, even with some uremic signs and a 
less marked functional derangement, will be more diffi- 
cult to prognose. Head and brain complications cannot 
be foreseen by means of renal functional tests. If the 
renal function remains fair, say 30% of phthalein out- 
put (Rowntree) and the blood tests do not show marked 
cumulative phenomena the prognosis is favorable and 
vice versa. 

In cardiorenal cases it is always difficult to deter- 
73 Trans. Cong. Amer. Physic, and Surg., 1913, IX, 23. 



174 Manual of Vital Function Testing Methods 

mine clinically just how much the heart and kidney are 
separately responsible for the conditions. Renal func- 
tional tests are of considerable service in showing just 
how far the kidney is affected. A low phthalein output 
with cumulative signs in the blood indicate a severe 
degree of renal involvement. In mere passive conges- 
tion these signs are not apt to be found. 

Moderately advanced nephritis with slight heart fail- 
ure may show a fairly good renal function, and, if so, 
the prognosis depends more upon the response of the 
heart to treatment than on the kidney. If the phthalein 
output increases in such cases it is a favorable sign, 
and if the phthalein output is fairly good in an appar- 
ently severe cardiorenal case, the heart may be judged 
the principal offender in the symptom complex. On 
the contrary, if the phthalein output is very low and 
there are signs of cumulation in the blood tests ( -[-urea, 
+rest nitrogen, low 8*) both kidneys and heart may be 
regarded as failing and the prognosis is grave. 

As a rule in cases of pure myocardial insufficiency 
the renal function tests give surprisingly good results. 
When the kidney is passively congested for long periods, 
however, as a result of heart failure, the functional 
tests give low results just as they do in severe types 
of nephritis. The prognosis becomes proportionately 
lugubrious. 

%. Surgical Application. — The surgeon is extremely 
interested in the problems of renal function. With him 
the question often becomes a very vital one in connec- 
tion with important and serious operations upon the 
genitourinary tract. The proper selection of tests is a 
matter of great importance to the surgeon. Geraghty 
rightly insists that it is only through familiarity with 
the reliability, limitations, and significance of findings 
* 5, symbol for freezing point of the blood. 



Tests of Kidney Function 175 

of individual tests of renal function, in their relation to 
various types of disease and various kinds of problems 
to be solved, that a proper selection can be made. 

Certain of the tests or combinations of tests are more 
suitable to surgical investigations, while other tests or 
combinations of tests may be of greater value to the 
internist. 

In discussing the utility of renal function tests to the 
surgeon, we shall draw freely upon Geraghty, since he 
more than any other investigator has identified himself 
in his researches with the question of their value and 
limitations in surgical practice. Some of the tests of 
renal function are adapted to estimating the total func- 
tional capacity of the kidneys at any given time. Other 
tests are not of great use in this respect but are of 
considerable importance in determining the relative 
functional capacity of the organs when applied to the 
excretion obtained by ureteral catheterization. Finally 
there are a few tests which are apparently useful in 
both cases. As an illustration, it is known that the 
estimation of urea output in a 24-hour specimen is 
of no great value by itself in judging the total func- 
tional capacity of the kidneys, while comparisons of 
urea elimination in catheterized specimens from both 
sides may give very important information. 

From a purely practical standpoint, as was men- 
tioned under preliminary considerations, all tests for 
kidney function come under two general heads: 1. 
Tests to determine how much of a given substance is 
excreted by the kidney or kidneys, comparing the 
amount with what is known to be normal. The sub- 
stance excreted may be one which is normally found 
in the urine or it may be a substance artificially intro- 
duced into the circulation to determine the capacity of 
the kidneys to eliminate it. 2. The blood may be exam- 



176 Manual of Vital Function Testing Methods 

ined for substances which are normally passed through 
the kidneys, with a view of detecting an accumulation 
of such substances in the body, such accumulation being 
regarded as an evidence of defective kidney function. 

Renal functional tests are especially valuable to the 
genitourinary surgeon in two types of cases : 1st, Sur- 
gical diseases of the kidney secondary to obstructions 
in the lower urinary tract. 2nd, Unilateral and bilateral 
surgical diseases of the kidney not associated with ob- 
struction. 

Rowntree and Geraghty, in many of their publica- 
tions concerning the phenolsulphonephthalein test, have 
called attention to the fact that inasmuch as many cases 
with obstruction in the lower tract also have hydroneph- 
rosis, pyonephrosis, pyelonephritis, or pressure at- 
rophy, an examination of the total function by means of 
the phthalein test will often show diminished functional 
activity. In these cases the urinalysis may be mislead- 
ing, for urea output and total solids secretion may be 
normal, and yet the kidney function may be so unstable 
that the shock of a surgical operation, such, for exam- 
ple, as prostatectomy, may be sufficient to inhibit func- 
tion altogether, and death will result. In just such cir- 
cumstances they believe a total examination by phtha- 
lein will serve to differentiate these cases with severe 
from those with slight renal involvement. 

Experience has shown that cases of obstruction in 
which the phthalein output is deficient may be so greatly 
improved by preliminary treatment with proper drain- 
age that the subsequent radical operation may be per- 
formed with greatly diminished risk. 

According to Geraghty the phthalein test affords the 
truest index of functional capacity of the kidney for 
surgical work. The diastase test and urea estimation 
are, he thinks, of equal value, but are unreliable indices 



Tests of Kidney Function 177 

of functional capacity; but when persistently low 
values are given by them they may be important from a 
prognostic point of view. Estimations of blood urea 
and incoagulable blood nitrogen are extremely impor- 
tant when they are associated with the phthalein test. 
When all three are positive they are extremely sig- 
nificant. 

The functional te^ts, one and all, can never be said 
to arbitrarily answer the important question, when to 
operate and when not to operate, because there are 
other factors to consider in a surgical case besides renal 
function. If the phthalein test is very low operation 
should be postponed until efforts are made by improved 
drainage (either by suprapubic cystotomy or by cathe- 
ter) to bring about improvement in the functional 
capacity of the kidneys. 

In the second group of surgical cases above men- 
tioned, namely, unilateral surgical kidney diseases, the 
relative functional power of the kidneys is a question 
of vital importance. It is here that ureteral catheter- 
ization is of supreme importance, for by this means the 
excretion from each kidney can be separately obtained. 

Many functional tests, such as urea estimations, cer- 
tain chromoscopic tests, as indigo carmin and methylene 
blue, cryoscopy, diastase estimation, phloridzin reac- 
tion, and experimental polyuria, give information only 
with respect to the relative functional value of the two 
kidneys. This is insufficient, since one kidney may be 
doing a great deal more work than the other, and yet be 
incapable of doing the work of both, and this is the 
question of vital importance to the surgeon, requiring 
a definite answer in each individual case. The phenol- 
sulphonephthalein test has proven of special value here 
because by it not only is an idea of the total functional 
capacity, but also a quantitative estimate of the work 



178 Manual of Vital Function Testing Methods 

done by each kidney obtained. 

There are two difficulties, however, which belong to 
all tests of renal function when carried out with ureteral 
catheterization; one is inhibition of function produced 
by the presence of the catheter in the ureter ; the other 
is leakage around the catheter. Special catheters are 
now used to prevent the latter difficulty. As to the first, 
the best method of procedure is to test the total func- 
tional capacity with phthalein before ureteral catheter- 
ization is performed. If the total phthalein output is 
nearly normal one kidney at least is satisfactorily nor- 
mal. If, after ureteral catheterization, one kidney is 
found with an exceedingly low output, which, together 
with the clinical findings, indicates that this is the dis- 
eased organ, it may be safely removed even if the output 
in the sound side is low, for here the natural inference 
is that inhibition has produced the deficiency. Inas- 
much, however, as inhibition is not necessarily equal on 
the two sides it will always be necessary to combine the 
phthalein test with comparison of diastase and particu- 
larly urea percentages, on the two sides. The actual 
procedure recommended by Geraghty is, first, the esti- 
mation of total output by phthalein and the estimation 
of relative function by ureteral catheterization com- 
bined with pigment, diastase and urea estimation on the 
two sides. If the phthalein output is low, cryoscopy of 
the blood serum and estimation of blood urea may 
profitably be done. 

Geraghty says : "Most of the criticism of functional 
tests has come from those who have not used them, and 
are unfamiliar with the nature of the information sup- 
plied. It is true that in the vast majority of cases a 
successful nephrectomy on the diseased side from the 
standpoint of renal function, can be performed when 
the urine from the opposite kidney is found apparently 



Tests of Kidney Function 179 

normal on analysis. Unfortunately, however, the prob- 
lems are not always so simple. Cases of bilateral dis- 
ease are encountered in which a knowledge of the renal 
function becomes of absolutely vital importance, and in 
which every source of information must be called upon 
before the proper line of procedure can be employed. 
Again, in certain cases, particularly those of tubercu- 
losis, it may be possible to introduce a catheter only on 
one side. In such cases one must depend to a great 
extent upon the information derived from function tests 
as to the condition of the opposite kidney since the cys- 
toscopic appearance of the ureteral orifice is frequently 
deceptive. The recognition of hypoplastic and infantile 
kidney is practically impossible without functional esti- 
mation. The infantile kidney is a particularly danger- 
ous type because the urine which is secreted by the kid- 
ney is apparently normal in every respect except that 
of quantity. Functional estimation has proved also of 
great value in the differentiation between pyelitis and 
pyelonephritis. In pyelitis the renal function is prac- 
tically normal, while in pyelonephritis there is dimin- 
ished function." 



SELECTION AND PRACTICABILITY OF RENAL FUNCTION 

TESTS 

In this regard we can do no better than quote the 
words of Geraghty, spoken at the conference on Renal 
Function Tests at the ninth triennial meeting of the 
Congress of American Physicians and Surgeons, 
1913 74 : 

"The number of functional tests has become so 
great that it is impracticable to employ all of them in 
any individual case; and, even if not impracticable, 
74 See Trans. Cong. Amer. Phys. and Surg., 1913, IX, 45. 



180 Manual of Vital Function Testing Methods 

nothing would be gained by employing all of these tests. 
The information furnished by many is of the same char- 
acter, but more accurately furnished by one test than 
by others. For example, there is a parallelism between 
the excretion of the different dye substances; but as 
phthalein furnishes more accurately all the information 
obtainable from this group of substances, no advantage 
attaches to the employment of all. 

"For chromocystoscopy alone indigo carmin is un- 
questionably the test of choice. The estimation of rest 
nitrogen and blood urea bear about the same signifi- 
cance. Lately we have discarded estimations of resid- 
ual nitrogen in the blood and are depending entirely 
upon the blood urea determined bv Marshall's method or 
upon cryoscopy for evidence of cumulative phenomena. 

"From a practical standpoint certain tests can be 
entirely discarded without loss, such as cryoscopy of 
the urine and electrical conductivity of the urine. Total 
urea estimations in urine are of doubtful value and dias- 
tase determination furnishes only information that is 
obtainable more accurately and quickly by other means. 
Certain other tests, such as potassium iodide elimina- 
tion, can be discarded as furnishing at times unreliable 
information. We have seen potassium iodide excretion 
delayed in cases with normal function (proven by sub- 
sequent history) and excreted within normal limits in 
cases of the most severe nephritis. The tests which 
we consider of the greatest value in the excretory group, 
based upon actual experience, are: Phthalein, lactose, 
and chlorides ; and of the tests of retention, blood urea, 
rest nitrogen and cryoscopy. The indications for the 
specific employments of the individual tests are as fol- 
lows: 

"Chloride estimation in the urine is useful in all 
forms of nephritis and cardiorenal disease, especially 



Tests of Kidney Function 181 

if oedema is present. 

"Lactose is indicated for the detection of slight in- 
jury to the kidneys and also in severe nephritis, since 
its suppression indicates a bad prognosis. It is not par- 
ticularly helpful in surgical diseases. 

"Of the retention tests either blood urea, rest nitro- 
gen or cryoscopy is indicated wherever there is a severe 
lesion of the kidneys. 

"We consider that one of these tests should be used 
as a routine in conjunction with phthalein wherever 
functional tests are desirable, particularly if the phtha- 
lein function is low. 

"Tests in conjunction with ureteral catheterization: 
in this connection, phthalein, urea in urine, and urinary 
diastase are most serviceable. The diastase and urea 
give practically the same information, but only give 
relative functional values, while phenolsulphonphthalein 
gives relative and absolute values. The total function 
should always be estimated by means of phthalein with- 
out ureteral catheterization, in order to detect the 
amount of catheter inhibition, should this exist. Where 
severe bilateral lesions exist, one of the retention tests 
should be used. 

"As to practicability, the simplest and easiest test is 
undoubtedly the phthalein test, as it requires the least 
amount of time and apparatus. 

"The lactose test, if quantitative determination is re- 
quired, necessitates the employment of an expensive po- 
lariscope. Furthermore the preparation of the lactose 
for injection requires attention and consumes time. Its 
use also requires familiarity with the technic of in- 
travenous injection. 

"Diastase requires the daily quantitative preparation 
of soluble starch, accurately graduated pipettes, a large 
series of test tubes, a water bath, and one-fiftieth nor- 



182 Manual of Vital Function Testing Methods 

mal iodine solution. For total estimation it requires 
24-hour specimens of urine with preservatives. The 
time necessary for a simple determination is scarcely 
warranted by the information obtained. Urea estima- 
tions of the urine can be accurately and rapidly done 
by the Marshall method; and from the standpoint of 
practicability it leaves little to be desired. It is useful 
only in conjunction with ureteral catheterization. 

"Chloride estimation requires standardized solutions 
and carefully graduated apparatus when accurately 
done. It consumes considerable time, and, besides, re- 
quires daily collections of the urine with the knowledge 
of the daily chloride intake. 

"All retention tests require, of course, the withdrawal 
of blood; and cryoscopy of the blood is undoubtedly the 
simplest, provided that proper apparatus is at hand. 
It requires careful attention to the details and con- 
sumes considerable time. 

"Blood urea can be done by either the Folin or the 
Marshall method, and the total rest nitrogen, preferably 
by Folin's method ; but any of these methods is imprac- 
ticable for the general practitioner. 

"Where only one test can be employed the most value 
is unquestionably to be obtained from the use of phtha- 
lein; and this is particularly so from the standpoint of 
the surgeon." 

Some of the suggestions and conclusions of Mosen- 
thal and Lewis seem especially pertinent. They par- 
ticularly warn against the phrase, "testing the kidney 
function as a whole," as it is a well-known fact that the 
various physiological units of the kidney do not func- 
tionate synchronously. Nor do they approve of using 
a single method for testing the renal function, to the 
exclusion of all others, as no test constitutes a method 



Tests of Kidney Function 183 

of kidney function. Each test has a significance of its 
own, and it is only by the use of the various tests that 
a real insight into the functi'on of the organ is obtained. 

They further propose a scale for a more definite 
nomenclature for the classification of the different de- 
grees of renal function. This scale will probably be 
changed from time to time, although appearing logical 
and practical at this time. This proposed grading of 
impaired renal function should prove a decided boon 
and should begin to bring order out of chaos. Hereto- 
fore, the terms "moderate" or "marked" indicated only 
what the author had in his mind at that time. Under 
the proposed classification, the terms "slight," "mod- 
erate," "marked," and "maximal" refer to definite 
mathematical values, something long sought in the med- 
ical diagnosis of the kidney conditions. 

The same authors have reached several conclusions 
which seem to be very important, and are as follows: 

The relationship between tests for nephritic function 
and prognosis has been found to be very uncertain. 
The extrarenal factors, cerebral hemorrhage, myo- 
cardial insufficiency, intercurrent infections, etc., have 
caused a fatal termination so frequently as to put a 
greater emphasis on the physician's clinical judgment 
than on the interpretation of tests for renal functions 
alone. 

The level of nonprotein nitrogen and urea nitrogen 
of the blood must be estimated largely as the resultant 
of three factors — kidney efficiency, diet and protein de- 
struction. In judging of prognosis, when these sub- 
stances are high in the blood of nephritics, due regard 
must be given as to whether their accumulation is 
brought about by retention alone or through retention 
coupled with protein destruction. The former offers 
a comparatively better prognosis than the latter. 



184 Manual of Vital Function Testing Methods 



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Tests of Kidney Function 185 

The coefficient of Ambard is a better method of de- 
termining the ability of the kidney to excrete urea 
than the level of this substance in the blood. 

The progress of renal disease is probably followed 
most minutely by means of the phenolsulphonphthalein 
excretion and Ambard's coefficient, as these tests fur- 
nish figures in which even small variations are of signifi- 
cance. 

The test meal for renal function, aside from the uric 
acid estimation in the blood, gives the earliest indica- 
tion of diminished kidney efficiency. It likewise reaches 
the maximum degree of impairment before the others. 

The value for early diagnosis of an increase of uric 
acid in the blood, and for prognosis, of an increase 
of creatinin in the blood, might well be emphasized. 

Each test for renal function covers only a limited 
range of the kidney's activities. It is, therefore, a mis- 
take to speak of any one test as measuring renal func- 
tion as a whole. The aim should be to develop a proper 
interpretation of the old tests and the easily applied 
new ones, in order to obtain a true guide to treatment 
of diseases of the kidney. 

See Mosenthal and Lewis: J. A. M. A., 1916, lxvii, 
933-938. 



CHAPTER III 
TESTS OF PANCREATIC FUNCTION 

GENERAL CONSIDERATIONS 

As Stadmiiller 1 rightly says, "The recognition in the 
living subject of pathological conditions of the pan- 
creas belongs, without doubt, to the more difficult prob- 
lems of the diagnostic technic of the present day." 

Aser 2 also said years ago that there is no organ in 
the body in which such a disparity exists between its 
known physiological importance and our capacity to 
clinically estimate its functioning power. 

In other words, the enormous importance of the pan- 
creas as a digestive organ and as a gland of internal 
secretion is granted, thanks to the work of Von Mering, 
Minkowski, Pawlow, Boldyreff, and many others. Our 
ability to estimate the functioning power, the physio- 
logical capacity, the anatomical condition of the organ 
in a given case is limited. 

The importance of the pancreas as a digestive gland 
is very great. It is the only gland which furnishes an 
enzyme for each class of foodstuffs. 

The activated proteolytic ferment trypsin breaks up 
protein into simpler structures (amino acids) than the 
gastric juice. Amylopsin or pancreatic diastase con- 
verts starch into sugar. Steapsin or pancreatic lipase 

1 Archiv. of Diag., 1911, IV, 20. 

2 Nothnagel's Spec. Path, und Therap., Wien, 1898, I. 

186 



Tests of Pancreatic Function 187 

splits neutral fats into fatty acids and glycerine. 
Glaessner has estimated that the pancreas pours into 
the duodenum through the ampoule of Vater perhaps a 
pint or more of its mixed secretion per day. 

But beyond this great act, which a priori would ap- 
pear to be more than sufficient for a single organ, the 
pancreas elaborates a mysterious secretion which pre- 
sides in an equally mysterious way over the sugar 
metabolism of the body. 

Von Mering and Minkowski in 1889 discovered that 
typical diabetes follows total extirpation of the pan- 
creas in dogs. This fact, which has received an immense 
amount of experimental corroboration, still stands out 
as an epoch-making discovery in the history of pan- 
creatic physiology amidst much that is obscure and un- 
certain. 

It is pretty generally agreed that the internal secre- 
tion of the pancreas is elaborated in the islands of 
Langerhans, closely crowded groups of polygonal cells 
without excretory duct of any kind scattered in the 
stroma of the gland between the external secreting 
acini and surrounded by a profusely developed net of 
blood vessels. 

Besides controlling the carbohydrate intermediate 
metabolism of the body the internal secretion of the pan- 
creas is claimed by Loewi and some others to exert an 
inhibitory effect upon the sympathetic. 

From the standpoint of the clinician it is an exceed- 
ingly difficult matter to determine the existence of 
pancreatic disease, and to ascertain its nature. All 
the customary methods of examination are, of course, 
employed in such a search. Inspection, palpation, 
blood examination, and a careful study of the semiology 
are made use of. The subjects of pancreatic semiology, 
pain, tenderness, tumor, pressure, etc., and pancre- 



188 Manual of Vital Function Testing Methods 

atic exploration are extremely important aids and in- 
dispensable adjuncts in pancreatic diagnosis. They 
do not come, however, under the functional investiga- 
tion of pancreatic activity, and will, therefore, be 
necessarily left undiscussed in this place. 3 

In considering the question of studying the functional 
capacity of the pancreas, two possibilities become im- 
mediately apparent. (A) Functional investigation 
may be made of the pancreas regarded as an organ 
of external or digestive secretion, and (B) the func- 
tional examination may relate to an inquiry concerning 
the internal secretory activity of the organ, its power, 
in other words, of adequately performing its endocrin- 
ous or metabolic function. 

I. TESTS FOR PANCREATIC FUNCTION, WHICH CONCERN 
THE EXTERNAL OR DIGESTIVE ACTIVITY OF THE ORGAN 

These may be divided into four subdivisions, as fol- 
lows : 

1. Proteid digestion tests. 

2. Fat digestion tests. 

3. Starch digestion tests. 

4. Demonstration of pancreatic ferments in secre- 

tions and excretions. 

The proteid digestion tests are: Demonstration of 
waste muscle fibre in the stools, the so-called azotor- 
rhoea or creatorrhcea. Schmidt's test for digestion of 
nuclei. Sahli's glutoid capsule test. 

The fat digestion tests are : Demonstration of ex- 
cess fat in the stools, so-called steatorrhea. Identifica- 
tion of split fat in the stools. Winternitz Diagnosti- 
cum. 
8 Consult Opie's Text Book, Diseases of the Pancreas. 



Tests of Pancreatic Function 189 

The starch digestion test consists of identification of 
undigested starch in the stools. 

Besides the above tests there have been devised special 
qualitative and quantitative methods of identifying the 
various pancreatic ferments themselves (trypsin, amyl- 
ase and lipase) in the stools, urine and gastric contents. 

It is somewhat difficult, therefore, to separate the 
operations of routine urinalysis and coproanalysis in- 
tended to show the presence or absence of pancreatic 
enzymes, from certain special tests which have been de- 
vised with the express purpose of testing pancreatic 
function. For example, Schmidt's test for nuclear di- 
gestion, and Sahli's glutoid capsule test might, upon 
superficial consideration, be considered as special tests 
for pancreatic function, but in reality they are both 
merely special methods of demonstrating the presence 
or absence in the intestine of pancreatic enzymes. 

However, the fact that in the performance of these 
tests something particular is done in the way of special 
preparation with a certain definite end in view, would, 
in all likelihood, insure their inclusion in any scheme or 
list of functional pancreatic tests. 

All the other tests mentioned in the above synopsis 
are, in reality, only special methods of urinalysis or 
fecal examination. 

The same difficulty of classification becomes apparent 
when we come to consider the tests of internal secre- 
tion. The Cammidge test, as it is called, is but a 
specially technical urinalysis. 

The Loewi test for pupillary reaction to adrenalin 
and the test for alimentary glycosuria might be said to 
answer all the requirements of special functional tests, 
but if our knowledge of pancreatic function were lim- 
ited to these experimental inquiries alone, it would be 



190 Manual of Vital Function Testing Methods 

meagre indeed. 

From all these considerations it will be apparent that 
any attempt to give a description of methods of study- 
ing pancreatic function must include all of the above- 
mentioned methods, although a very strict interpreta-^ 
tion might relegate some or many of them to the domain 
which is usually covered by books dealing with chemical 
or microscopical laboratory methods. 

II. TESTS FOR PANCREATIC FUNCTION WHICH CONCERN 

THE INTERNAL OR METABOLIC FUNCTION OF 

THE ORGAN 

There are three tests which belong to this class. 

1. The Cammidge reaction. 

2. Loewi's pupillary reaction. 

3. Provocative alimentary glycosuria. 
These will be described in their proper place. 

1. Proteid Digestion Tests. Estimation of Undigested 
Protein in the Stools as a Means of Determin- 
ing Pancreatic Hypof unction 

The patient is placed for three days on Schmidt's 
test diet. This diet is as follows: 1.5 liters of milk, 
100 gms. of zwieback, 2 eggs, 50 gms. of butter, 125 
gms. of beef, 190 gms. of potatoes, and gruel made from 
80 gms. of oatmeal. In this diet are contained 102 gms. 
of albumen, 111 gms. of fat, 191 gms. of carbohydrates ; 
making a total of 2234 calories of energy. 

According to Schmidt the diet is distributed through 
the day as follows: Morning, .5 liter of milk (if milk 
does not agree .5 liter of cocoa made from 20 gms. of 
cocoa powder, 10 gms. sugar, 400 gms. water and 100 
gms. milk are substituted), 50 gms. zwieback; noon, 125 



Tests of Pancreatic Function 191 

gms. chopped beef (raw weight) broiled rare, with 20 
gms. of butter (the interior of the meat must be raw), 
250 gms. of potato broth made of 190 gms. of mashed 
potatoes mixed with 100 c.c. of milk and 10 gms. of but- 
ter; afternoon, same as morning; evening, same as fore- 
noon. 

It would be well if investigators should agree to use 
this well-known standard diet so that comparisons of 
results could be made. 

Pratt, 4 while using the diet, recommends that the 
whole quantity be given in three meals instead of five, 
conforming thus to American custom. 

The Schmidt diet, containing as it does a good 
amount of all three varieties of foodstuffs, is adapted to 
all tests which involve an examination of the feces. 

The presence of azotorrhoea or defective proteid 
digestion due to deficiency of trypsin zymase, is deter- 
mined by examining the feces microscopically after the 
test diet. 

Meat consists of connective tissue and muscle fiber. 
Connective tissue is digested promptly by the gastric 
juice, the muscle fiber by trypsin. Large quantities of 
striated muscle fiber in the feces may indicate defective 
pancreatic activity. 

The bulkiness of the stools should also be noted. 
Oser, Musser and others have claimed that there is 
no single symptom of pancreatic disease of greater 
significance than bulkiness of the stools. The dried 
weight of the stools may be rather readily ascertained. 
A ventilating hood and scales are all that are necessary. 
If the pancreatic juice is not appearing in the bowel the 
dried stools will weigh more and the stools themselves 
will be more than ordinarily voluminous. 

In six healthy individuals on Schmidt's diet Pratt 
4 Amer. Jour. Med. Sc, 1912, CXLIII, 313. 



192 Manual of Vital Function Testing Methods 

found the average weight of the dried feces to be 54.3 
gms. The maximum was 62 and the minimum 45 gms. 

Schmidt's Cell Nuclei Test for Pancreatic Suf- 
ficiency. 5 — According to Schmidt, the nuclei of animal 
cells is digested only by the pancreatic enzymes. Con- 
siderable has been written pro and con concerning this 
test and, although it does not appear to be extensively 
used, there is no doubt that it is not devoid of a certain 
value. 

Technic. — Raw beef somewhat fibrous is cut into 
cubes of .5 c.cm. These are hardened in alcohol and 
placed in small bags of coarse silk gauze. Before using 
they must be soaked several hours in water. The bags 
are recovered in the stools, hardened, paraffined, cut and 
stained, and the sections mounted and examined micro- 
scopically for nuclei. If the nuclei are not digested, 
they will take the stain and become visible. Thymus 
gland has been substituted for the meat by Einhorn. 

Kashiwado, one of Schmidt's pupils, has altered the 
original test by giving a powder consisting of equal 
parts of stained thymus nuclei and lycopodium. The 
mixture is given in two capsules, each containing .25 
gm., at the evening meal. The stool is examined for 
stained nuclei. 

In performing the Schmidt test the sac must be 
recovered in the feces before the expiration of 30 hours 
at the latest, otherwise a longer sojourn in the bowel 
will enable the bacterial enzymes to dissolve the nuclei. 

Sahli's 6 Glutoid Capsule Test of Pancreatic Func- 
tion. — The glutoid capsules used in this test are made 
of gelatin and hardened in formalin. This is intended 

■ Verhandl. d. Kong. f. inn. Med., 1904, XXI, 335. 
6 Deutsch. med. Wchnschr., 1897, XXIII, 6; also Deutsch. Ar- 
chiv f. klin. Med., 1898, LXI, 475. 



Tests of Pancreatic Function 193 

to make them resist digestion by the gastric juice, to 
permit of their entering the bowel, there to be softened 
and disintegrated by the pancreatic juice if it be pres- 
ent in sufficient amount. It is the trypsin zymase which 
affects this solution. 

The capsules may be filled with sodium iodide, iodo- 
form or salol. The last is usually employed. Salol is 
split up by the pancreatic juice into salicylic acid and 
phenol. The former is eliminated by the kidney and 
escapes in the urine as salicyluric acid, which is easily 
recognized in the excretion by the violet color produced 
by adding to the urine a few drops of a solution of 
ferric chloride. 

Normally the reaction is obtained in five hours. 
Sahli did not disclose the precise manner of preparing 
the capsules and this, according to Pratt, has hindered 
the generalization of the test which is so extremely 
simple. 

The capsules are made and sold by Hansmann of St. 
Gallen, Switzerland. 

Sailer 7 says that a satisfactory capsule may be 
prepared by placing ordinary gelatin capsules in pure 
formalin for three minutes. 

This test is practically the same as that introduced 
by Sahli for estimating gastric motility. Its extreme 
facility of execution would make it an excellent test if 
there were unanimity in the findings. Unfortunately 
this is not the case and at the present time no one would 
pretend to depend upon its results alone, though it 
seems undoubtedly true that in the absence of pyloric 
spasm or stenosis, the capsule test of Sahli is worth 
considering from a corroborative point of view. 

7 Amer. Jour. Med. Sc, 1910, CXL, 330. 



194 Manual of Vital Function Testing Methods 

#. Fat Digestion Tests. Demonstration of Excess of 
Fat in the Stools (Steatorrhea) and Diminu- 
tion of Split Fats in the Stools as a Means of 
Estimating Pancreatic Insufficiency 

Here the insufficiency of pancreatic function, if it 
exists, is reflected upon the fat-splitting activity of the 
external secretion and shows itself by phenomena which 
are due to diminution or absence of the lipasic enzyme 
of the juice. 

Steatorrhea, or increased fat in the stools, is known 
to be common in pancreatic disease. The light color 
of the stools is an important macroscopic feature. They 
may be almost white. The stools are often rancid in 
smell and bulky. Since the stools in icterus may also 
be fatty it may be necessary to test for bile in order to 
make sure that the pale color is not due to hydrobiliru- 
bin. When fat crystals are present in excess, the stools 
have a metallic lustre like aluminum. A white stool, 
fluid when passed and becoming solid on cooling, is fatty 
and is said to be quite characteristic of defective pan- 
creatic secretion. The most important function of pan- 
creatic lipase is to split up the neutral fats into fatty 
acids and glycerine. The free fatty acids combine with 
the alkalies of the pancreatic juice to form readily 
assimilable soaps. 

If the functional activity of the pancreas is deficient, 
one important consequence will be a considerable dim- 
inution in the amount of split fats, and hence of 
soaps. The fat will remain unsplit, therefore unassimil- 
able and consequently unabsorbed. 

Normally from 7 to 11% of the fat ingested in the 
food escapes action by the pancreatic juice and is 
passed in the stools. If bile is absent from the intestine 
because of occlusion of the duct, there will be incomplete 



Tests of Pancreatic Function 195 

emulsification of the fats and consequent reduction of 
pancreatic effects. Under such circumstances as much 
as 45% of the fats ingested may escape in the stools. 
If, in a case of icterus, the loss of fat in the stools is less 
than 60% the pancreas is probably not implicated. If 
the fat loss exceeds 60% it points to pancreatic disease. 

Under the microscope, fat appears in the stools as 
droplets, needle crystals, or as structureless plates or 
flakes. Unfortunately the quantitative estimation of 
fat in the stools is not a simple matter. The stools must 
first be dried on a water bath; the neutral fats and 
fatty acids are extracted in a Soxhlet apparatus with 
ether, from a known quantity of dried stool ; the residue 
is treated with diluted HC1 to convert soaps into fatty 
acids and these are extracted in the same manner. The 
amount of free acid in the first extract is calculated with 
titration with alkali. 

Like the Cammidge reaction or test (v.i.) the quanti- 
tative estimation of fat in the feces is not to be regarded 
as a clinical procedure likely to be carried out by the 
physician. The method requires some apparatus and 
more chemical experience than the clinician is likely to 
possess and, besides, is time consuming. Of course, in 
many hospitals, the examination can readily be made. 
It is not considered advisable to give the details of the 
method for fat extraction and quantitative estimation, 
the skeleton of which is above outlined, especially as 
the details may readily be obtained from texts on 
chemical diagnosis. For convenience two references 
may be given— Sahli 8 and Wood. 9 

Winternitz's Test of Pancreatic Fat-splitting Func- 
tion. Winternitz Diagnosticum. The Sajodin Test. — 
This test is founded upon the fat-splitting power of 

8 Diagnostic Methods, 1905, p. 446. 

9 Chemical and Microscopical Diagnosis, 1909, p. 334. 



196 Manual of Vital Function Testing Methods 

steapsin to set free iodine from iodine-containing fats. 
Winternitz was the first to apply the artificially iodized 
fats to the investigation of the fat-splitting power of 
the pancreatic juice. The first substance used was iodi- 
pin, but it was found that the iodine present in this sub- 
stance is so firmly bound that even normal pancreatic 
juice may not split it. He finally selected monoiodo- 
behenate of calcium or sajodin as the most suitable sub- 
stance. 

Sajodin is a thin, oily liquid containing 25% of 
iodine. If 3 c.c. of this substance are administered by 
mouth to a fasting individual and the urine examined 
for iodine 3 to 5 hours later the reaction will be nega- 
tive. If the same substance in the same amount is 
given with a meal, the iodine reaction will be present. 
In the first instance no pancreatic secretion has been 
stimulated to appear in the duodenum and consequently 
the sajodin is not split. In the second instance the 
opposite prevails. 

It was further found that in cases of icterus no 
splitting of sajodin takes place because of the absence 
of bile salts in the intestine, which are necessary to 
actuate the fat-splitting ferment and to stimulate ab- 
sorption. 

Several investigators have investigated the Winter- 
nitz test and the question has been made the subject 
of a thesis by Stegman. 10 He concludes that the failure 
to find iodine in the urine 3-5 hours after the ingestion 
of 3-5 c.c. of sajodin with a meal, is indicative of lipo- 
lytic pancreatic insufficiency in most cases, and that, 
in combination with other well-known tests, the method 
of Winternitz may be regarded as of considerable cor- 
roborative value. 

10 Ueber eine neue Methode der Pankreasfunktions prufung 
Winternitz Diagnostikum. Dissertation Otto Stegman, 1911. 



Tests of Pancreatic Function 197 

In a recent inaugural dissertation upon the Winter- 
nitz sajodin test by Syring, 11 this author finds that 
without exception in normal cases iodine appears in the 
urine in 3-5 hours after the ingestion, with a meal, of 5 
c.c. of calcium monoiodobehenate (sajodin). 

The question $s to its real value in determining the 
existence of pancreatic insufficiency can only be settled 
by further investigations. 

3. Starch Digestion Test. Identification of Undi- 
gested Starches in the Stools as an Evidence of 
Pancreatic Insufficiency 

The presence of starch in the stools is generally un- 
derstood to be of little value in this connection. Nor- 
mally scattered granules of undigested starch are to be 
found and can be easily identified under the microscope, 
when stained with iodine solution (Lugol's), which 
colors them blue. Any great excess, however, may 
fairly awaken suspicion, especially if there is persistent 
diarrhoea and the condition tends to be permanent or 
long continued. Under these circumstances it is legiti- 
mate to conclude that there is pancreatic insufficiency. 

If. Identification of Various Ferments. Tests Where 
Examination Is Made for the Pancreatic Fer- 
ments Themselves in the Excreta. The Meaning 
and Interpretation of These Results in Relation 
to Estimating the Pancreatic Function 

The different pancreatic ferments can be demon- 
strated by proper methods, in the stomach (after an 
oil meal), in the urine, and feces. 

Einhorn, Gross, and others have devised special ap- 
11 Ueber die Funktionsprufung des Pankreas. Leipzig, 1913. 



198 Manual of Vital Function Testing Methods 

paratus for obtaining the pancreatic juice directly from 
the duodenum. Einhorn's duodenal tube is used consid- 
erably in this country, but more particularly for thera- 
peutic purposes. 

One objection which urges against all tests for tryp- 
sin in the stools is that erepsin, a ferment coming from 
the mucous membrane of the small intestine, may digest 
albumen, etc., even in the absence of trypsin. The ob- 
jection cannot be urged against the gastric estimations, 
and, in fact, seems to be exaggerated even when applied 
to fecal analysis methods. 

Demonstration of Trypsin in the Stools. — Two 
methods are chiefly used ; the Serum Plate method and 
the Casein method. 

The Serum Plate Method of Muller and Schlecht. 12 — 
Trypsin acts upon the surface of serum agar plates. 

Method. One drop of the stool obtained by a laxa- 
tive (calomel or phenolphthalein) is placed upon a 
Loffler serum agar plate and kept at a temperature of 
55° to 60° C. for 6-12 hours in an incubator. 

If trypsin is found in the stool there will appear a 
depression or hole in the serum due to digestion by the 
enzyme. 

Ordinary diphtheria culture tubes have been sug- 
gested by Stadmuller as being sufficient for the purpose 
of the test. 

This test is simple and seems to be rather highly re- 
garded (Brugsch, Hirshberg, etc.). Other practical 
methods of demonstrating trypsin in the feces have been 
devised. Arthur and Hubert add a 2% solution of 
sodium fluoride to the stools, also fibrin, and incubate 
at 40° for 24 hours. Crystals of tyrosin are formed if 
trypsin be present. Abderhalden's technique has also 
been employed, using glycyl-tyrosin. The Miiller- 

12 Munch, med. Wchnschr., 1908, LV, 225. 



Tests of Pancreatic Function 199 

Schlecht method is sufficient, however, and much more 
simple. 

For a quantitative variation of the serum agar plate 
method of stool examination for trypsin, put in one part 
of the plate undiluted feces and in orderly sequence 
in other portions of the plate use dilutions of the feces 
1 : 10, 1 : 20, 1 : 100, 1 : 200, and note which still forms 
indentation. If the stools are fatty the fat should be 
extracted with ether. 

The Casein Method of Demonstrating Trypsin in the 
Stools. — Casein in alkaline solution is precipitated by 
dilute acetic acid. If casein is digested by trypsin it 
will no longer give the precipitation reaction with dilute 
acetic acid. This is the foundation of a test devised 
by Gross. 13 

In Gross' method the feces are mixed with an alkaline 
solution of casein — .1% casein, .1% sodium carbonate. 
Various quantities of the filtered feces are added to the 
casein solution, incubated for an hour and tested with 
dilute acetic acid (v.i.). 

Mette's tubes are also sometimes used in testing for 
the presence of trypsin. They consist of glass tubes 
about 1 or 2 mm. in diameter, containing coagulated egg 
albumen. These are suspended in the dilute feces or 
other solution to be tested for a fixed time and the 
amount of albumen digested off, measured. The 
strength of the ferment will be proportional to the 
square of the length digested. 

Technic of Gross 9 Quantitative Test for Trypsin. — 
Prepare a .1% solution of casein by adding 1 gm. of 
pure casein (Merck) and 1 gm. of sodium carbonate to 
1000 c.c. of chloroform water. Place in a flask and 

u Arch. f. Exper. Path, und Pharm., 1907, LVIII, 157; also 
Deutsch. med. Wchnschr., 1909, XXXV, 1706. 



200 Manual of Vital Function Testmg Methods 

allow to stand for 24 hours, after which the solution 
is shaken vigorously. 

Five gms. of feces are placed in a mortar. Add 45 
c.c. of 1% solution of sodium carbonate. Titrate 
thoroughly and filter. The first cloudy portion of 
filtrate is discarded. The second is used. 

To each of six reagent glasses marked for identifica- 
tion add 10 c.c. of the casein solution. With graduated 
pipette add respectively 1 gm., .5 gm., .25 gm., .2 gm. 
and .1 gm. of filtered feces to specimen and mix thor- 
oughly. Place all in incubator, adding to each 3 drops 
of 1% acetic acid. Specimens in which the casein are 
digested (presence of trypsin) will remain clear; others 
are cloudy. 

In normal stools, glasses 1 to 3 are clear, 4 to 6 
cloudy. A trypsin unit equals the amount of feces 
which digests 10 c.c. of starch casein solution. If .33 
gm. feces which is diluted tenfold digests 10 c.c. of 
casein solution, there are 30 trypsin units, which is nor- 
mal. In clinical work, disease of the pancreas may be 
suspected when no trypsin or, at most, 10 units are 
found in examination of the feces. 

Demonstration of Trypsin in the Stomach Contents. 
Method of Boldyreff-Volhard. 14 — Boldyreff noted in 
1904 in Pawlow's Institute that feeding olive oil to dogs 
caused regurgitation of duodenal contents into the 
stomach. Volhard 15 applied the principle to the clinic. 

A breakfast of 200 c.c. of olive oil is given by stom- 
ach tube or 250 c.c. of cream may be substituted, the 
latter being swallowed. Half a teaspoonful of magnesia 
usta are given just prior to the meal and is repeated 

"Centrbl. f. Physiol., 1904, XVIII. 457; also Zentbl. f. Phys. 
und Path. d. Stoffw., 1909, III, 209. 

16 Munch, med. Wchnschr., 1907, LIV, 403. 



Tests of Pancreatic Function 201 

twenty minutes afterward. This is to prevent acidifica- 
tion. At the end of 45 to 60 minutes, the stomach con- 
tents are removed by tube. Usually a liquid is obtained 
which tends to separate into two layers, the lower one 
containing the duodenal juice. 

The presence of trypsin can be demonstrated by the 
Gross casein test described above or by that of Arthur 
Hubert, 16 previously mentioned, the details of which 
follow : 

Fresh fibrin obtained from horse blood by whipping 
and washing the coagulum is covered with 2% solution 
of sodium fluoride and kept for 24 hours at 40° C, 
then filtered. 

The fluid to be examined is diluted with equal volume 
of 2% sodium fluoride solution, and one volume of this 
dilution is added to two or three volumes of the fibrin 
solution and digested at 40° for some hours. Crystals 
or crusts of tyrosin form on the wall of the vessel. 

According to Sahli trypsin can qualitatively be most 
easily demonstrated by digesting in alkaline fluid at 
incubator temperature a flake of fibrin stained with 
magenta red. The fibrin becomes digested and dissolved 
and the fluid is colored red. 

Stadmuller mentions a simple qualitative test devised 
by Von Oefele. A few drops of Fehling's alkali solution 
with a few drops of a 1-1000 solution of casein are 
added to a .07% copper sulphate solution and .1% 
sodium carbonate. The mixture is incubated at 55°. 
To 5 c.c. of this, in a warm test tube, are added five 
drops of the fluid (intestinal juice) to be tested, the 
whole being shaken. If trypsin is present the solution 
which at first is blue or green if bile is present becomes 
red-violet or rose color. 
"Archiv. de Physiol., 1894, 622. 



202 Manual of Vital Function Testing Methods 

Estimation of Diastatic and Lipolytic Ferment m 
the Feces as a Measure of Pancreatic Function. — 
The results obtained by a study of the diastase con- 
tent of the stool should, provided all controllable fac- 
tors in performing the test are standardized, give val- 
uable information concerning the functional integrity 
of the pancreas. The physiological basis upon which 
the test is founded is, that practically the whole amount 
of diastatic ferment found in the feces is of pancreatic 
origin, i.e., provided certain possible sources of error 
are understood and obviated (Wohlgemuth). 

Several satisfactory methods for estimating diastase 
in the feces have been devised, chief of which are those 
of Wohlgemuth 17 chiefly used in Germany ; that of 
Durand, 18 chiefly used in France and England, and that 
of Brown, 19 chiefly used in the United States. The 
methods of Durand and Brown will be described. 

Durand 9 s Method of Estimating Diastase m the 
Feces. — One c.c. of the total diluted feces is added to 
50 c.c. of starch solution (1% starch and 2% decinor- 
mal HC1). The tubes are incubated for half an hour 
at 39.5° C. and digestion is then stopped with three 
drops of strong soda solution. The sugar formed is 
estimated quantitatively with Fehling's solution. 

Ten c.c. Fehling's solution is reduced by .0124 gm. 
of sugar. If x be the number of c.c. of the incubated 
mixture used to reduce the Fehling's solution, the 
amount of sugar present in the 51 c.c. of the mixture 

will be — : or, in the whole amount of the 



1T Biochcm. Zeitsch., 1908, IX, I; also ibid., 1909, XXX, 432. 

18 Archiv. des Mai. d. Appar. Digest., 1911, V, 76. 

19 Johns Hopkins Hosp. Bull., 1914, XXXV, 200. 



Tests of Pancreatic Function 203 

feces (obtained as below),- " This 

figure is multiplied by two to give units of grams of 
sugar formed in the hour. The normal limits are 1500- 
2000 units. 

The feces for the test are obtained as follows: The 
patient is well purged 12 hours after his last meal. He 
is then given % liter of milk and 45 minutes later 50 
grams sodium sulphate in water, and one-half hour after 
this a glass of vichy. The feces of the next 3^/2 hours 
are passed into a vessel containing ice. They are then 
diluted with water to 20 liters and tested as above. 

Technic of Brown's Test. — The patient is given a 
high enema the night before. The evening meal should 
be very light. At 7 A. M. the next morning 750 c.c. of 
milk are given. At 7:30 and again at 8:30 A. M. ^2 
ounce of Epsom salts are taken. At 8:30 a glass of 
water containing *4 teaspoonful of sodium bicarbonate 
is swallowed. 

All stools up to 2 P. M. are saved in a vessel con- 
taining 2 ounces of toluol which is kept in a cool room 
or on ice. If less than 400 c.c. of stool are obtained 
an enema of a pint of water is given. The average 
quantity collected up to 2 P. M. will be from 400 to 
1100 c.c. usually. 

The stool should be examined as soon as possible 
after 2 P. M. Dilute the amount up to 3000 c.c. with 
normal salt solution, stir the whole amount until abso- 
lutely homogeneous. Centrifugalize a portion for 5 
minutes and use the supernatant fairly clear fluid for 
testing. 

Diminishing amounts of the fluid are put into a series 
of tubes, 1.8 c.c. in the first, 1.6 c.c. in the second, 1.4 
c.c. in the third, 1.2 c.c. in the fourth, 1 c.c. in the 



204 Manual of Vital Function Testing Methods 

fifth, .8 c.c. in the sixth, .6 c.c. in the seventh, A c.c in 
the eighth, .2 c.c. in the ninth, .1 c.c. in the tenth, .05 
c.c. in the eleventh and .025 c.c. in the twelfth. Bring 
the fluid in each of the tubes up to 2 c.c. with normal 
salt solution. If the test shows a negative reading in the 
first tube or if a low reading is expected, a supplemen- 
tary set of tubes is prepared containing respectively, 2 
c.c, 3 c.c, 4 c.c, and 5 c.c. centrifugalized mixture. 

In each of the tubes is added 2 c.c of 1% solution 
of soluble starch (Kahlbaum) and the tubes are incu- 
bated at 38° C. in water bath y% hour, then cooled by 
adding a little tap water and by holding them under 
the cool tap. They are then quickly tested with a few 
drops of one tenth normal iodine solution. The limit 
is held to be that tube before the one in which the first 
definite blue color appears. 

Demonstration of Lipolytic Ferment. — Two simple 
tests for the presence of lipolytic ferment may be men- 
tioned. These are the Grutzner-Gamgee 20 method and 
the von Oefele 21 method. 

The first is as follows : An emulsion of ten parts of 
oil, five parts of gum and thirty-five parts of water is 
prepared. A neutral solution of litmus is made up 
which in test tubes of 12 mm. diameter appears violet 
against white paper. Ten c.c of litmus solution and 
5 drops of the emulsion are placed in several of these 
tubes and increasing quantities, 2, 4, 8, 16, 32 drops, 
of the fluid to be tested are added to the successive test 
tubes. These are put in a water bath at 37° C, and af- 
ter a short time the tubes are compared. If any fat- 
splitting ferment is present the color of the fluid will 
have turned redder the larger the amount of solution 
added. 

20 Quoted by Stadmuller, loc. cit. 

21 From Sahli's Diagnostic Methods, 491. 



Tests of Pancreatic Function 205 

Von Oefele's method of demonstrating steapsin is as 
follows: sweet butter is melted and the resulting clear 
fat mixed with an equal proportion of a 1% aqueous 
solution of potassium carbonate and some phenolphtha- 
lein, and then titrated with a soda solution until there is 
a red tint. This liquid is heated in the incubator to 
55° C. and 5 c.c. of it well shaken in a warm test tube 
with 5 drops of intestinal juice. In the presence of a 
normal amount of steapsin the red tint will disappear 
in from 2 to 5 minutes. According to the rapidity of 
the discoloration the quantity of actual steapsin can 
be estimated. 

H. TESTS FOR PANCREATIC FUNCTION WHICH CONCERN 

THE INTERNAL OR METABOLIC FUNCTION OF 

THE ORGAN 

All the functional tests of pancreatic activity which 
have been described have related to the external secre- 
tion with its enzymes, which is poured out through the 
pancreatic duct and the ampoule of Vater into the 
small intestine. 

There is, however, another phase to the question of 
functional deficiency of the pancreas and this relates 
to its internal secretion, which in some mysterious or 
quite unknown manner presides over the mobilization 
and destruction of sugar in the body. When the in- 
ternal secreting function of the pancreas is lowered, 
the power of assimilation of carbohydrates is reduced 
and when a certain limit is reached a hyperglycemia 
results which tends at a certain point to manifest itself 
by the elimination of sugar in the urine, glycosuria, 
diabetes. 

There are three functional tests which concern par- 
ticularly the internal function of the pancreas. These 
are: 



206 Manual of Vital Function Testing Methods 

1. The Cammidge Reaction. 

2. Loewi's Pupillary Reaction. 

3. Provocative Alimentary Glycosuria. 

1. The Cammidge Pancreatic Reaction 

There is still much dispute as to just what position 
the reaction holds in the clinical diagnosis of pancreatic 
function. 

The original Cammidge reaction consisted of two 
parts or analyses which were known as A and B tests. 
It was held that the presence of a pancreatic lesion 
and even its nature could be determined by these tests. 
The original theory upon which the test was based was 
about as follows. If there is a real pancreatic lesion, 
the pancreatic juice will escape into the parenchyma 
of the organ and lead to fat necrosis with splitting 
of neutral fat into fatty acids and glycerine. 

The fatty acids will remain in the necrotic areas 
and the glycerine will be absorbed into the blood and 
excreted by the urine. The Cammidge test was de- 
vised to demonstrate the presence of glycerine in the 
urine by the presence of glycerosazone crystals. 

The original theory was subsequently modified and 
the two original tests were abandoned and replaced 
by one process known as the C test. The present 
theory of the Cammidge test is this. The crystals 
produced in the test when positive, result from the 
presence in the urine of a sugar complex which upon 
hydrolysis with HC1 yields a substance giving a pentose 
reaction. The crystals of a positive reaction are be- 
lieved to be pentosazone. 

The pancreas contains four or five times as much 
pentose as any other organ in the body and conse- 
quently when any disintegration of pancreatic tissue 



Tests of Pancreatic Function 207 

takes place as a result of disturbance or disease of the 
organ, crystals of pentosazone, the Cammidge crystals 
will be demonstrated in the urine. Neither a mere 
blocking of the pancreatic secretions nor a pure fibrosis 
of the organ will produce a positive reaction. It is 
usually held as Cammidge himself believes that a posi- 
tive reaction is evidence of active degeneration such 
as occurs in acute or chronic pancreatitis. A negative 
reaction contraindicates active degeneration but does 
not exclude old pancreatitis nor malignant disease of 
the pancreas. In fact, in 75% of malignant cases the 
reaction is negative. But the test is not always posi- 
tive even in pancreatitis and a negative test does not 
definitely exclude pancreatitis. The results must al- 
ways be taken in conjunction with clinical, urinary and 
fecal findings. The test is not considered generally by 
pathologists or clinicians as having great practical 
value in diagnosis. But when positive it constitutes an 
interesting abnormality which seems to be connected 
in some rather cryptic or obscure manner with dis- 
turbances of the pancreatic function. 

Technic of the Cammidge Test. — Filter a portion of 
a 24-hour specimen of urine. 

Test for Albumen. — If albumen is present in amount 
more than a trace, measure out 50 c.c. of filtrate and 
add a few drops of acetic acid, boil, cool, filter and 
make up to 50 c.c. 

Test for Sugar. — Either Fehling's or Nylander's 
test is performed. The result must be absolutely nega- 
tive. If there is any reduction on standing about 50 
c.c. of the albumen free urine must be mixed with 
yeast fermented for 12 to 24 hours and filtered. 

Stage I. Measure 20 c.c. of the clear albumen and 
sugar free filtrate into a small flask with an in- 
verted filter funnel placed in its mouth as a condenser. 



208 Manual of Vital Function Testing Methods 

Add 1 c.c. of strong HC1. Boil on sand bath for 10 
minutes from commencement of ebullition. The boil- 
ing should not be too vigorous and the flame should 
be turned low for the greater part of the time. 

Stage II. Cool under the tap. Make up contents 
to 20 c.c. with distilled water. Slowly add 4 gms. of 
lead carbonate; shake gently at first and more thor- 
oughly later. Stand, and shake occasionally until no 
more gas comes off. Filter through a paper moistened 
with distilled water. 

Stage III. Add 4 gms. of powdered tribasic acetate. 
Shake thoroughly for some minutes and allow to stand. 
Filter through a moistened filter paper. 

Stage IV. To the clear and almost colorless filtrate 
add 2 gms. of powdered sodium sulphate, shake thor- 
oughly for several minutes. Bring slowly up to the 
boiling point on a sand bath, shaking from time to 
time. The excess of lead is removed at this stage and 
it is important that the shaking and heating should 
be done carefully. 

Stage V. Cool under the tap and filter. Measure 
10 c.c. of clear filtrate. Make up to 18 c.c. with dis- 
tilled water. Add 8 gms. of phenyl-hydrazine hydro- 
chlorate, 2 gms. powdered sodium acetate and 1 c.c. 
of 50% acetic acid. 

Boil in a flask with a funnel condenser on the sand 
bath for 10 minutes from the commencement of ebulli- 
tion. Do not boil too vigorously. Filter hot through 
a filter paper moistened with boiling distilled water 
into a 15 c.c. measure. Should the filtrate fail to reach 
the 15 c.c. mark make up to 15 c.c. with hot distilled 
water. Stand for from 4 to 5 hours or longer at room 
temperature or in ice chest. 

Examine the filtrate for the appearance solubility 
and amount of crystal formation. 



Tests of Pancreatic Function 209 

The typical crystals examined under the microscope 
are of the osazone type and more circular and tuft-like 
than glucosazone crystals. Run under the cover slip 
33% H 2 S0 4 ; the crystals should dissolve in 10-15 sec- 
onds. The crystals have to be distinguished from the 
coarse yellow needles which may be deposited if the ex- 
cess of lead was not removed in Stage IV. In a strongly 
positive reaction the deposit of crystals may occupy 
half the bulk of the filtrate. In a completely negative 
reaction the filtrate remains clear. 

0. hoewVs Pupillary Symptom or Test of Pancreatic 

Insufficiency 

In 1908 Loewi 22 made the observation that after re- 
moval of the pancreas in certain animals, the instilla- 
tion of adrenalin into the eye will cause dilatation of the 
pupil. Ordinarily the instillation of adrenalin into the 
eye does not cause dilatation altho intravenous injec- 
tion will do so. Loewi attributed the mydriasis fol- 
lowing instillation to increased excitability of the sym- 
pathetic system brought about by the removal of the 
inhibitory effect of the pancreatic internal secretion. 

From this fact it was thought that a mydriasis in man 
following local instillation of adrenalin would indicate 
pancreatic internal insufficiencj 7 , provided hyperthy- 
roidism or Graves' disease did not exist. 

According to Sladden 23 this test has given interest- 
ing and encouraging results and should not be dis- 
missed with the comparatively scant attention it has 
received lately. 

The technic of the test is extremely simple since it 
consists merely of dropping into the conjunctional sac 

22 Archiv. of Exper. Path, and Pharm., 1908, LIX, 83. 

23 Quart. Jour, of Med., 1913-14, VII, 455. 



210 Manual of Vital Function Testing Methods 

a few drops of a 1 : 1000 solution of adrenalin and ob- 
serving the effects upon the pupil. 

3. Spontaneous and Provocative Alimentary Glyco- 
suria in Their Relation to Pancreatic Function 

The intimacy of relationship between the pancreas 
and control of the carbohydrate metabolism is close 
and undisputed, but what particular cells of the pan- 
creas are concerned or just what the mechanism of the 
control may be is very imperfectly understood. Glyco- 
suria is usually present in many of the more serious 
pancreatic diseases, but glycosuria is by no means an 
infallible index of either the extent or the nature of 
the pathological processes. In many cases of pan- 
creatic disease, however, glycosuria does not appear 
(e.g. many cases of chronic pancreatitis, carcinoma, 
etc.). According to Cammidge the presence of glycosu- 
ria means only a one to three chance that the pancreas 
is diseased, and in case of pancreatic disease about one 
in fourteen shows sugar in the urine. The truth is 
well expressed by Sladden when he says, "viewed arith- 
metically, glycosuria is not a sign of great diagnostic 
value." If, however, glycosuria either spontaneous or 
provocative be present together with other confirmatory 
evidence of pancreatic disease the symptom then ac- 
quires a greater value. 

It must be remembered that the liver is also concerned 
to a very important and intimate extent with carbo- 
hydrate metabolism, and tests for alimentary glycosuria 
have long been employed with a view of estimating the 
functional integrity of that organ. Under a previous 
chapter these tests have been given and discussed. 

It must be perforce admitted that the question of 
applying the so-called carbohydrate tests for provoca- 



Tests of Pancreatic Function 211 

tive glycosuria to the elucidation of pancreatic func- 
tion is one which for the present must be left open. 

It would appear rational to assume that the pres- 
ence of glycosuria after the provocative tests indicates 
either hepatic or pancreatic insufficiency or both, and 
such tests are never in themselves sufficient to elucidate 
the problems involved, but where they are corroborated 
by other more specific evidences of insufficiency, they 
assume an importance in diagnosis of no mean value, 
an importance which is entirely lacking to them when 
interpreted alone. 

GENERAL CONCLUSIONS CONCERNING THE TESTS FOR 
PANCREATIC INSUFFICIENCY 

It is certainly true that no one functional test of 
pancreatic activity so far devised constitutes an abso- 
lute or pathognomonic sign of disease of this organ. 
It is quite natural that this should be so in view of the 
manifold functions of the pancreas. 

In other words it is often a very difficult question 
to determine in a given case whether the pancreas 
is diseased or insufficient at all, much less to make out 
by means of the most complete and comprehensive 
semeiological study the precise nature and extent of 
the pathological processes. 

The whole subject of pancreatic clinical pathology 
and diagnosis and that of tests for functional activity 
of the organ is in its infancy. 

Nevertheless the value of those functional tests so 
far devised is considerable and it is the duty of clini- 
cians to apply them in practice to such an extent that 
their individual and collective worth or lack of worth 
may be definitely determined. 



CHAPTER IV 
TESTS OF HEART FUNCTION 

GENERAL, CONSIDERATIONS 

In recent times a considerable transformation has 
occurred in the viewpoint of clinicians toward the 
cardiopathies and cardiac pathology. A few years 
ago all cardiopathology was discussed in terms of 
anatomical lesion. The chief interest lay in the exact 
localization and delimitation of the lesion. The ten- 
dency at the present is to bring more and more into 
the foreground the idea of functional capacity of the 
organ. Recent studies in cardiac physiology and 
pathology have shown that the fundamental factor is 
the muscle itself rather than its innervation as was be- 
fore believed. It has been likewise shown that the func- 
tion of the cardiac muscle is a complex one and that 
at least five subdivisions of function may be made 
(Englemann). These may be enumerated. The heart 
muscle possesses the power of originating contractile 
impulses (impulse formation, chronotropic function); 
it possesses the faculty of susceptibility to the receipt 
of these functions (excitability, irritability, bathmo- 
tropic function) ; it is endowed by means of the conduct- 
ing system of fibers including a histological differenti- 
ated tissue, the bundle of His with power to transmit 
these impulses from the point of their formation, the 

212 



Tests of Heart Function 213 

sino-auricular node to the cardiac muscular fibers (the 
conducting function, conduction, dromotropic func- 
tion) ; it possesses the fundamental power of contrac- 
tion (contractility, inotropic function), and finally, the 
muscle possesses that vital function by which it nor- 
mally refuses to dilate beyond a certain point (tonic- 
.ity). 

A perfect method of estimating cardiac function 
would be one in which all these five functions of the 
cardiac muscle could be separately measured. The 
function of the entire organ would be then their arith- 
metical sum if all possessed some degree of integrity, 
or their algebraic sum if certain of them were below a 
normal point which might be diagrammatically repre- 
sented by zero. But as a matter of fact we are far 
from being able to accomplish such an estimate of 
cardiac function at the present time. 

There are many instances, however, in which a care- 
ful physical examination of the organ together with 
the use of special methods of cardiac investigation 
which have come into use in recent years (sphygmo- 
graph, electrocardiograph, sphygmodynamometer, the 
X-ray) will enable the physician to conclude that one 
or more of the five functions of the cardiac muscle are 
deficient. 

When some or all of these functions have become 
so insufficient and incompetent that the occurrence of 
heart failure (asystole) is imminent, the symptoms 
of the condition (cyanosis, decompensation, edema, 
signs of venous congestion) become so patent and evi- 
dent that the presence of cardiac insufficiency is simple 
to recognize from a study of the physical signs and 
the symptoms. 

This stage of true insufficiency may be called a ter- 
minal stage of the cardiopathies no matter what the 



214 Manual of Vital Function Testing Methods 

anatomical lesion may be in a given case. This stage 
is known, however, to be preceded by a long period of 
latency in which cardiac insufficiency, if it is present, 
cannot be so easily discovered and has to be looked 
for in order to be recognized. 

It is the desire of the clinician to increase his powers 
of observation, to so lengthen as it were his cardiac 
vista, that he may be enabled to recognize the earliest 
signs of cardiac incompetency. It is for this very evi- 
dent reason that tests for estimating the integrity of 
heart functions have been devised. As yet no one of 
them has succeeded in providing an entirely adequate 
means of obtaining this much to be desired end, never- 
theless several interesting and valuable methods have 
been developed. The work of the past gives promise of 
future developments and improvements in this extreme- 
ly important domain of functional diagnosis. 

To Rosenbach is generally given the credit of in- 
sisting upon the necessity of devising proper tests 
by which the functional integrity of this most im- 
portant organ, the heart, might be measured. 

The various methods of testing the cardiac func- 
tion may be divided into a few classes. The first and 
largest group includes those tests which depend upon 
the reaction of the heart muscle to various types of 
exertion active or passive. There is a second and 
much smaller group based upon the behavior of the 
heart to reflex stimulation. A third and extremely 
insignificant group includes but one test, based upon 
the supposition that sodium chloride elimination is 
effected by cardiac insufficiency. A fourth group in- 
cludes modern clinical and instrumental methods of 
investigating cardiovascular conditions so far as they 
are concerned with the question of elucidating heart 
functional power. 



Tests of Heart Function 215 

The following synopsis shows how the various tests 
are to be placed in the four categories above mentioned. 

I. Reaction to muscular exertion active or passive 
as a basis for estimating cardiac function. 

1. The staircase test. 

2. Graupner's test. 

3. Mendelsohn's test. 

4. Katzenstein's test. 

5. Herz's self-checking test. 

6. Gymnastic resistance test. 

7. The Russian test — "Holding the breath" test. 

8. The Venous pressure test. 

II. Application of cardiac reflex estimations in de- 
termining heart function. 
Merklen's test. 
III. Estimation of sodium chloride elimination as a test 
of cardiac sufficiency. 
Vaquez-Digne test. 
IV. Modern clinical and instrumental methods of in- 
vestigating cardiovascular conditions : their 
applicability to estimating cardiac function. 
1. The sphygmomanometer as an index of cardiac 
function. (Work velocity ratio; sphygmobo- 
lometry sphygmobolography, energometry, 
etc.) 

6. Rontgenoscopy and Rontgenography as indices 

of cardiac function. 

7. Sphygmocardiography and electrocardiogra- 

phy; their relation to cardiac functional 
capacity. 

I. REACTION TO MUSCULAR EXERTION ACTIVE OR PAS- 
SIVE AS A BASIS FOR ESTIMATING CARDIAC FUNCTION 

The majority of the methods so far suggested for 
estimating heart functional power have consisted in 



216 Manual of Vital Function Testing Methods 

the subjection of the patient to a certain measured 
degree of physical exertion followed by the systematic 
observation of the phenomena produced by the exer- 
tion as compared with conditions carefully ascertained 
prior to the beginning of the test. 

All these methods, however, have the common objec- 
tion that the same work prescribed to different indi- 
viduals, will under normal circumstances produce quite 
different results, according to certain circumstances, 
among which are the size and general muscular 
strength of the individual, the usual mode of life with 
respect to physical exertion, the condition of the nerv- 
ous system, etc. The result, therefore, of exertion 
tests may not always be comparable even in healthy 
persons. If these factors can be properly estimated 
and provided for the exertion tests are rendered more 
certain and hence more useful. 

Herz has emphasized the fact that the cardiac phe- 
nomena produced by exertion tests are varied by the 
type of effort attempted: whether, for example, the 
movements are rhythmical and gymnastic, whether they 
are resisted or not, and especially whether the muscular 
groups called into play are weaker or stronger. A 
much higher rise of blood pressure is produced by the 
effort attempted by a weaker set of muscles than the 
same operation performed by a stronger set. Grebner 
and Grunbaum have contended that the increase in 
blood pressure produced by muscular contractions is 
inversely proportional to what may be termed the 
specific energy of the muscles employed in the effort. 

The influence of psychic factors in varying the re- 
sults of muscular tests has always been recognized 
(Kornfelds). The same may be said of the nerve 
factors. All these facts tend of course to render un- 
certain the results obtained by the exertion tests (pulse 



Tests of Heart Function 217 

rate, blood pressure), but even with these defects this 
type of method of estimating cardiac function is of 
practical value. 

The chief points taken into consideration in this 
type of test are the rate of the pulse, the blood pressure 
(systolic and diastolic) and the area of cardiac dull- 
ness or size of the heart (percussion, rontgenography). 

As long ago as 1833 Donnell showed that the pulse 
rate is normally slower in the recumbent than in the 
semi-erect and erect positions. Christ in 1894 1 pro- 
posed to register the exact pulse rate after exertion 
with the sphygmograph provided with a time marker. 
He likewise invented an apparatus by which the patient 
could undertake a measured amount of exertion on 
a steppage machine. Rosenbach in the same year em- 
phasized the importance of noting the condition of 
the skin after the performance of the exertion. It 
was his belief that the skin remains dry if the heart is 
competent but becomes quickly moistened with perspir- 
ation if there is cardiac insufficiency. He explained the 
increased sudation on the ground that the excretory 
function of the skin is called from the list of reserve 
forces to compensate as far as possible for the cardiac 
inadequacy. This is probably not the correct interpre- 
tation of the phenomenon since sweating itself re- 
quires the expenditure of force. It is probably due 
to vasomotor causes. 

1. The Staircase Test. Selig's Test 2 

Technique. — Count the pulse and take the systolic 
pressure. Have the patient ascend a flight of twenty 
steps, rapidly. Count the pulse and take the systolic 
pressure after the ascension. 

1 Archiv f . klin. Med., 1894, LIII, 1902. 
a Prag. med. Wchnschr., 1905, XXX, 418, 432. 



218 Manual of Vital Function Testing Methods 

Under normal circumstances, there is an increase 
in the pulse rate of 20 beats per minute on an average 
and a rise of blood pressure of 8 millimeters of Hg. 

If the myocardium is insufficient there will be an 
increase in the pulse rate of 30 beats per minute or 
more. The blood pressure rise will be slower and 
average about 6 mm. of Hg. The rise may be fol- 
lowed rather suddenly by a fall below normal or the 
preliminary rise may be absent. 

The length of time required for recovery to the 
normal systolic pressure may be taken as a measure 
of the amount of cardiac insufficiency present. 

The staircase test on account of its simplicity is often 
employed by clinicians. 

The "hopping test" is a modification of the Selig 
test, which has been used for years as a routine method 
of eliciting a latent cardiac insufficiency. The patient 
is instructed to hop 20 paces on one foot and a com- 
parison is then made between the pulse rate before 
and after the exertion. 

One serious objection to the "hopping test" is that 
the actual amount of work performed by the indi- 
vidual to be tested cannot be computed. In the method 
of climbing stairs, the amount of energy expended can 
be approximately known. The amount of work done 
in foot pounds will be equal to the product of the 
weight of the individual in pounds into the number of 
feet ascended. 

The advantage of this simple test is that it can be 
performed without any special apparatus, which is the 
chief objection from a practical standpoint to some 
of the functional cardiac tests which have been sug- 
gested. 



Tests of Heart Function 219 

#. Graupner's Test 3 

Graupner found at Nauheim in observing the reac- 
tion of patients after the exercises carried out as a 
part of the treatment of cardiopathies, that persons 
with weakened hearts showed a different type of reac- 
tion from those with normal or nearly normal myo- 
cardia. 

Under normal circumstances, as is well known, the 
pulse rate and the systolic blood pressure rise after 
exertion, returning to normal after a fairly short in- 
terval. If the exertion is sufficiently prolonged and 
arduous they may fall below the normal. Graupner 
discovered that after the pulse rate has risen and again 
fallen to normal after an exertion, the systolic pres- 
sure rises gradually to a maximum, which is reached 
in a few minutes, usually about six, declining to normal 
in about 18 to 20 minutes. The rise of blood pressure 
following the pulse rise is called the normal erholung. 
In weakened hearts, even if the weakness is slight, 
Graupner found that the erholung occurs but it is less 
in amount than normal and is delayed beyond the 
normal interval, usually to about 12 minutes. If the 
heart is seriously weakened the erholung may be ab- 
sent altogether, the blood pressure declining from the 
start then gradually rising to normal. In normal cases 
the pulse reaches its normal in 5 to 10 minutes. 

Technique of Graupner's Test. — A Zuntz Ergom- 

eter 4 of the bicycle or weight and pulley type is used 

in conducting the test. The patient turns a wheel 

which is supplied with a brake and adjustments for 

measuring the amount of work expended. Tests are 

8 Berl. klin. Wchnschr., 1902, 1T4; Deutsch. med. Wchnschr., 
1906, XXXII, 1029. 
4 Centrbl. f. Physiol., 1898, 502. 



220 Manual of Vital Function Testing Methods 

made on successive days at the same hour. The work is 
therefore done by the same muscle groups. It is im- 
portant not to carry the work to the point of exhaus- 
tion or strain. Mental excitement must be absent. 
The pulse rate, blood pressure and size of the heart 
are noted before and after the test. 

Arm muscle work may be substituted for thigh muscle 
work on the same machine and this was done by Graup- 
ner in his later researches. 

Cabot 5 and Bruce have recommended using a meas- 
ured amount of stair climbing, which of course is a 
more practicable and generally useful method. They 
estimate the amount of work in foot pounds which is 
readily computed by multiplying the number of pounds 
the individual weighs by the number of feet ascended. 

Graupner came to the following conclusions as a 
result of his rather extensive investigations: If the 
blood pressure remains constant after the exercise the 
heart muscle is sufficient. If the blood pressure falls 
after the exercise there is cardiac insufficiency. If the 
blood pressure rises but returns to normal there is com- 
pensatory sufficiency.* If the blood pressure rises then 
rapidly falls without a tendency to subsequent rise the 
heart muscle is fatigued. 

Graupner stated as his belief that if the pulse is 
accelerated and the patient becomes short of breath 
after the performance of work equivalent to 45 to 300 
kilograms the heart is manifestly insufficient. 

Several authors have corroborated Graupner's view 
that a persistent tendency toward a fall of blood pres- 
sure after the exertion denotes cardiac insufficiency. 
According to Graupner's later observation persons 
with normal hearts can perform arm muscle work on 
the ergometer equivalent to from 3,000 to 20,000 kilo- 

■Amer. Jour. Med. Sc, CXXXIV, 190T, 491. 



Tests of Heart Function 221 

grams per hour. If the figures fall below 1000 kilo- 
grams per hour there is cardiac insufficiency. If meas- 
urements are made every half minute after exercise it 
was found that the amount of variability in the blood 
pressure corresponds with the insufficiency of the heart, 
in other words, that the greater the heart weakness 
the greater are the variations in the pressure and the 
longer the time required for the status quo to be 
restored. This does not wholly occur for 30 to 35 
minutes. 

Some observers have found that a lowering of the 
blood pressure after exertion may be found in trained 
athletes and according to the terms of the test this 
should denote cardiac insufficiency. But as Hirsch- 
felder 6 states, "the heart of the trained athlete is 
habitually throwing out an amount of blood suited 
not to the needs of the moment but to the needs of 
the periods of exercise to which he has accustomed 
himself." The systolic output is above normal when 
the exercise (and hence the increased production of 
C0 2 ) is slight. The heart is then able to take care of 
the excess of C0 2 production in exercise without in- 
creasing the output and hence the vasodilatation in 
the muscles is the only factor influencing the blood 
pressure. When the exercise becomes severe the other 
mechanisms begin to play a role. 

Also in certain patients with diseased hearts the 
blood pressure has been found to rise, it is claimed, 
because of high pressure stasis. This rise, however, 
comes later than in normal cases. 

Cabot and Bruce as a result of their trial of Graup- 
ner's test in seventy-five experiments believe that it is 
reliable. They say "the main outlines of Graupner's 
contention can be easily verified by anyone. Run 

6 Hirschf elder, Diseases of the Heart and Aorta, p. 286. 



222 Manual of Vital Function Testing Methods 

quickly up two flights of stairs and then stop and 
count your pulse. After the immediate acceleration 
is passed or during the slowing of the pulse following 
it you will note that the heart beat and the strength 
of the pulse become markedly exaggerated. One feels 
the thump thump of the heart against the ribs much 
more strongly after the pulse has almost or quite 
reached its normal rate than during the period when 
the pulse is most accelerated. ... As regards the 
phenomenon designated by Graupner as the normal 
erholung we can verify his findings and we likewise 
agree with him in the results of our experiments upon 
seriously weakened hearts. In some of the cases be- 
lieved by us from ordinary examination of the heart 
to be normal there was considerable variation from 
the ordinary curve of blood-pressure after exertion. 
Cases of valvular disease with good compensation 
showed, as might have been expected, a normal curve." 

Tests like that of Graupner in which blood pres- 
sure estimations are used as a criterion of cardiac 
function are founded upon observations of Masing 7 
and others that the normal blood pressure rises during 
exercise and falls immediately afterward. 

When a normal individual exercises with chest 
weights, for example, the blood pressure may rise 10 
to 30 mm. of Hg. If the individual is arteriosclerotic 
the rise of blood pressure may go to 40 to 60 mm. of 
Hg. and outlast the exercise a variable length of time. 

Bauer in employing this test used a stationary bicycle 
and this is a good method because the blood pressure 
estimations can be easily taken in the arm during the 
performance of the exercise. According to Bauer the 
bicycle test gives for normal individuals a rise of 5 to 10 
mm. of Hg., while in those with cardiac insufficiency 
T Deutsch. Arch, f . klin. Med., Leipz., 1901, LXXI, 253. 



Tests of Heart Function &%& 

there may be a fall of equal degree (5 to 10 mm. of 

The great difficulty with this test is that it has been 
found that in trained athletes the blood pressure may 
fall instead of rising at the commencement of mild ex- 
ercise and the fall may last for a considerable period, 
thus making the reaction of the strong man some- 
what similar to that of the weak. The proper interpre- 
tation of this fact has been given. 

As Hirschfelder states all functional tests of cardiac 
efficiency if based upon mathematical changes in pulse 
and blood pressure may lead to ambiguous results. 
This is no objection, however, to the application of the 
tests but only to their too strict interpretation. The 
appearance of the patient after the performance of 
the physical tests is of course extremely important. 
Accelerated or labored breathing, holding the breath, 
dilatation of the nostrils, drawing in of the corners of 
the mouth, darkness or pallor of the cheeks, sweating, 
palpitation and so forth, all these are signs of cardiac 
insufficiency more important perhaps than the mathe- 
matical results of individual tests. 

According to Hirschfelder the most reliable nu- 
merical criterion of cardiac efficiency is whether a given 
strain causes the heart to diminish in size (increase 
in tonicity) or to dilate (decrease in tonicity — over- 
strain). 8 

3. Mendelsohn's Test 9 

Technic. — The pulse is carefully counted in the 
standing, sitting and recumbent postures and the fig- 
ures noted. This may be repeated several times and 

8 Hirschfelder, loc. cit, 199. 
•XIX Kongr. f. Inn. Med., 1901. 



224 Manual of Vital Function Testing Methods 

an average taken. The person to be tested then per- 
forms muscular work upon a Gaertner ergostat by 
means of which the amount of work may be measured. 10 
The Gaertner ergostat is an instrument not easily se- 
cured and for this reason the original test is not much 
employed. By the simple method, however, of Cabot 
and Bruce above mentioned of having the patient per- 
form a given amount of work in stair climbing which 
can be easily calculated, the reaction of the pulse rate 
and the return of the latter to normal, which is the 
basis of the Mendelsohn tests, can be readily estimated. 
After the performance of varying amounts of work the 
patient assumes the recumbent posture immediately 
and the time is noted which is required for the pulse to 
return to the normal figure previously ascertained for 
that posture. 

The first criterion of the Mendelsohn test is based 
on the principle that when the heart is healthy or well 
compensated, a transition from vertical to horizontal 
position is accompanied by a slowing of the pulse of 
10 or 12 beats per minute. If the heart is insufficient 
or decompensated an opposite condition may prevail, 
namely, the pulse becomes quicker in the recumbent 
posture or tends to remain constant. 

Mendelsohn contended that if there is not a well 
marked difference in the pulse rate between the erect 
and recumbent postures the heart is incompetent. 

The second criterion suggested by Mendelsohn de- 
pends upon the principle that the competent heart 
is able to return immediately to a normal when rest- 
ing after a strain. He suggested, therefore, that an 
estimate of the functional capacity of the heart can 
be obtained by noting the degree of facility displayed 
by the organ to return to normal conditions after meas- 
10 Allg. Wien. Med. Zeit., 1887, Nos. 49 and 50. 



Tests of Heart Function 225 

ured exertion in which extra cardiac energy is called 
into play. Mendelsohn found that a normal heart 
after performing work equivalent to 100-200 kilograms 
returns immediately to the normal with rest in recum- 
bent posture. After 500 kilograms of work the normal 
heart is accelerated somewhat for a varying period of 
time. If, however, there is cardiac insufficiency very 
much smaller amounts of muscular exertion prove exces- 
sive and disturb the pulse rate. A disturbance of rate 
with failure to return immediately to normal following 
the expenditure of 25-50 kilograms of work denotes 
cardiac insufficiency. 

A Variant of Mendelsohn's Test. — When a normal 
individual rises from the reclining to the standing posi- 
tion the heart rate is accelerated, but it is usually 
stated that the increase ought never to be more than 
20. Beyond 20 one has the right to assume that the 
myocardium is insufficient. 

This test from its extreme simplicity has been much 
used and is capable of giving some valuable informa- 
tion. But nevertheless, under some circumstances it 
fails to do so; for example, under conditions where 
the psychic role may play a part. Here the increase 
of pulse rate in a normal individual, that is normal so 
far as the myocardium is concerned, may be inordinate 
and out of proportion. Hirschfelder 1X says that per- 
sons with enteroptosis may give a false increase. 

^. The Katzenstein Method 12 

Katzenstein found from animal experiments that 
ligature of peripheral arteries produces an increase in 

u International Clinics, Vol. IV, 1910, p. 39. 
"Deutsch. med. Wchnschr., 1904, No. 30, p. 807; also, ibid., 1907, 
XLIV, No. 16. 



226 Manual of Vital Function Testing Methods 

the general blood pressure without change in the pulse 
rate. In animals with weakened hearts he demonstrated 
that ligature of peripheral arteries produced other re- 
sults, namely increased pulse frequency and irregulari- 
ties in the blood pressure. He therefore proposed ap- 
plying the principle involved to clinical medicine as an 
aid to determining the functional capacity of the heart 
muscle. 

His method consists essentially in making compres- 
sion upon peripheral arteries (the femorals) so as to 
shut off the circulation in the lower limbs, and observ- 
ing the effects upon the pulse and blood pressure. The 
author of the test found in cases of cardiac insufficiency 
a lowering of the blood pressure and a simultaneous 
increase in the pulse rate, both of which deviations 
from the normal appeared to maintain a proportionate 
relation to the incompetency of the heart muscle. 

It has been proposed to substitute an Esmarch band- 
age for digital compression of the arteries, thereby 
doing away with the necessity of an assistant. 

Technic of Katzenstein Test. — Sometimes called also 
the Marey-Katzenstein-Shapiro Test. 

The patient is put in a reclining posture and the 
pulse rate and blood pressure taken. Pressure is then 
made for two and one-half to five minutes over both 
femoral arteries in the groins by means of the fingers 
of an assistant or by elastic Esmarch bandage, or 
according to Morelli by inflatable rubber stockings. 
The pulse rate and blood pressure are again recorded. 

In normal individuals with sufficiency of the myocar- 
dium the pulse diminishes in number. The blood pres- 
sure rises 5 to 15 mm. of Hg. With sufficient but 
hypertrophic hearts the pulse diminishes or remains 
the same. An increase of 15 to 40 mm. of Hg. takes 
place in the blood pressure. 



Tests of Heart Function 227 

In cases of moderate latent cardiac insufficiency the 
blood pressure remains unchanged. The pulse rate 
is unchanged or increased. In higher grades of cardiac 
insufficiency the blood pressure sinks and the pulse 
rate increases. 

For practical purposes it may be said that with 
sufficiency of the heart muscle the pulse remains un- 
changed or diminishes in number and the blood pres- 
sure rises. If the pulse increases and the blood pres- 
sure remains the same or falls after the Katzenstein 
test the heart is insufficient. 

Norris 13 made an investigation in 1907 with a view 
of determining the adaptability of Katzenstein's test 
to clinical use. He found that generally speaking the 
results were accurate and confirmatory of its author's 
findings but many exceptions were noted. Some of the 
cases, many in fact, of cardiac weakness which re- 
sponded positively to the test did so in an extremely 
equivocal manner, leaving practically the final deter- 
mination a matter of personal equation on the part of 
the investigator. 

As a corroborative test the method of Katzenstein 
appears to possess some value, but as an independent 
test of cardiac sufficiency or insufficiency no great de- 
pendence can be placed upon it. The method should 
be used with caution in cases of severe cardiac weak- 
ness where it may prove to be actually dangerous. 

5. Herz's Self -Checking Test. 14 Selbst-Hemmungs 

Probe 

Technic. — The patient is placed in a sitting posture 

and remains so until the pulse rate has become con- 

18 Blood Pressure and Clinical Applications, Phila., 1914, p. 145; 
International Clinics, 1907, I, 17s, p. 66. 
"Deutsch. med. Wchnschr., 1905, 31, XXXI, 215. 



228 Manual of Vital Function Testing Methods 

stant. He is then directed to contract all the muscles 
of hand and forearm with all his force and to flex and 
extend the forearm with all possible force, performing 
the motions slowly, paying strict attention to the per- 
formance and endeavoring to antagonize his movements 
as forcefully as possible. 

In healthy persons the pulse rate is unaffected by 
this maneuver, whereas in persons with a weak heart 
the rate increases 5 to 20 beats per minute. 

This test has been found to possess a certain degree 
of reliability but it does not possess so absolute a value 
as was originally ascribed to it by its author. Some- 
times healthy persons give a positive reaction. Hirsch- 
felder believes that the vagus plays a part in it and 
that the results are not altogether indicative of cardiac 
output and vigor. 



6. Gymnastic Resistance Test. Herz-Haranchipy 

Test 



This consists in having the patient execute three 
types of resisted movements. First a movement of 
flexion-extension of the forearm, the patient being 
seated. Second, a movement of separation-approxi- 
mation of the thighs in sitting posture. Third, a move- 
ment of abduction-adduction of the extended lower 
limbs, the patient seated. All of these motions are re- 
sisted equally. A slight rest is given between each 
series. The whole test lasts 25 to 30 seconds. Prior 
to the movements the systolic blood pressure is taken. 
While the movements are being executed and during 
repose the blood pressure is retaken. In a normal in- 
dividual there should be a variation in the blood pres- 



Tests of Heart Function 229 

sure as a result of the exercises of not more than 10 
to 15 mm. of Hg. In cases of cardiac insufficiency it 
reaches 20 to 30 mm. of Hg. 

7. The Russian Test. 16 "Holding the Breath" Test 

This simple test for estimating the integrity of the 
cardiac muscle has been in long use empirically. We 
have called it the Russian test because Herz has men- 
tioned the fact that he could not find any specific men- 
tion of it in the literature but knew that it was com- 
monly employed by certain Russian physicians. 

The test is well called "Holding the Breath" test 
since it consists simply in directing the patient to stop 
breathing for as long a time as possible. This ma- 
neuver puts a considerably added strain upon the 
myocardium, particularly the right ventricle. Great 
variations of the length of time in which the breath 
can be held by different persons are found, but any 
marked limitation of the time during which a person 
can inhibit the act of respiration indicates cardiac 
insufficiency. If the period of voluntary apnoea is 
less than 15 seconds the myocardium may be considered 
insufficient. 

8. The Venous Pressure Test. Schott's 16 Test 

The principle of the Schott test depends upon the 
fact that in health if the arm is elevated to an angle 
of 60 degrees with the patient in a recumbent posture 
and making no other exertion the venous pressure in- 
creases only .5 cm. of H 2 or sometimes may remain 

"Die Herz Krankheiten, Wien, 1919, p. 195. 
ie Deutsch. Arch. f. klin. Med., 1919, CVIII, 537. 



230 Manual of Vital Function Testing Methods 

stationary or even fall. If, however, the cardiac muscle 
is insufficient, a rise in the venous pressure takes place 
which may even be considerable (4 to 7 cm.). Accord- 
ing to Schott, any reading above 3 cm. denotes cardiac 
insufficiency. 

Several methods have been devised to determine ven- 
ous blood pressure. Von Frey and Gaertner considered 
that the venous pressure can be determined by con- 
sidering it equal to the height above the angle of 
Ludwig at which the veins of the hand are seen to 
collapse when the arm is raised. Von Recklinghausen 
used an apparatus whereby the vein could be compressed 
by inflating a small rubber capsule provided with a 
glass window in the top of a rubber dam floor with an 
opening in its center. The dam is coated with glycerine 
to insure perfect apposition to the skin. It is placed 
over a vein on the back of the hand or wrist and the 
system inflated until the vein is seen to disappear, at 
which point the pressure is read off on a water ma- 
nometer. Eyster and Hooker modified the method by 
using an aluminum chamber with a glass top, the two 
ends concave to avoid pressure on the vein. The 
normal venous pressure obtained by this instrument at 
the sterno-xyphoid articulation is 5 to 10 cm. of H 2 0. 
In cardiac cases it may rise to 27 cm. or more. The 
pressure in the lip capillaries may be estimated by using 
the point of blanching as the criterion. The study of 
venous pressure is of some importance as an index of 
accumulation of blood in the veins and may therefore 
become to some extent an index of heart failure. 



Tests of Heart Function 231 



II. APPLICATION OF CARDIAC REFLEX ESTIMATIONS IN 
DETERMINING HEART FUNCTION 



Merklen's Test 

The best known cardiac reflexes are those of Abrams 
and Livierato. 

Abrams' reflex consists of a diminution of the area 
of precordial dullness following energetic friction over 
the heart. Livierato's reflex consists of an increase of 
the area of cardiac dullness following percussion over 
the epigastric region. In Abrams' reflex the left ven- 
tricle is chiefly affected and in Livierato's reflex the 
right ventricle. The heart is so much less meiopragic 
(weakened) in proportion to its capacity to give a 
positive Abrams and a negative Livierato. 

Technique of Reflex Test. — Map out the area of 
precordial dullness carefully by light percussion and 
mark with dermographic pencil. Make precordial fric- 
tion for one minute, using rough cloth or a rubber 
eraser. Follow this by rapid percussion of the pre- 
cordial area. After three to five minutes' wait, map out 
the area of dullness by light percussion. If the reflex 
is normal, the area will be smaller than before. 

In using Livierato's reflex the technique is the same 
to determine the area of cardiac dullness. The reflex 
is elicited by making a series of rapid rather forceful 
strokes for one minute over the median line of the ab- 
domen. After three minutes' interim, the area of dull- 
ness is again made out and if the reflex is positive the 
right border of cardiac dullness will be found increased. 
The two reflexes should not be applied to the same pa- 
tient on the same day. 



232 Manual of Vital Function Testing Methods 

III. ESTIMATION OF SODIUM CHLORIDE ELIMINATION AS 
A TEST OF CARDIAC SUFFICIENCY 

Vaquez-Digne Test 

This test is based upon the supposition that the 
elimination of sodium chloride is affected by the suf- 
ficiency or insufficiency of the heart muscle. In indi- 
viduals in whom the integrity of the heart muscle is 
normal any excess of salt ingested should be promptly 
eliminated from the circulation had passed out through 
the kidney. In cases of cardiac insufficiency even when 
latent, it is contended that the salt elimination is defec- 
tive. 

In applying this test the individual is put for some 
days on a fixed sodium chloride ration and when an 
equilibrium is established the amount of salt injected 
is doubled and a quantitative estimation of sodium 
chloride in the urine made. In cases of cardiac in- 
sufficiency there will be defective elimination and if 
the diminution of function is considerable there may 
be oedema and signs of partial decompensation set up. 
The integrity of the kidney function must be previously 
determined. 



IV. MODERN CLINICAL AND) INSTRUMENTAL METHODS 
OF INVESTIGATING CARDIOVASCULAR CONDITIONS: 
THEIR APPLICABILITY TO ESTIMATING CARDIAC FUNC- 
TION 

1. Sphygmomanometer as an Index of Cardiac Func- 
tion. Work-Velocity Ratio 

The sphygmomanometer is the instrument in vogue 
of our day. The chief value of this instrument is to 



Tests of Heart Function 233 

register the height of the blood pressure and since its 
introduction it has no doubt contributed to a clearer 
differentiation of states of hyper- and hypotension. 
Like the sphygmograph, it is teaching physicians to 
become more expert in the use of their sense of touch 
and just as the latter instrument (sphygmograph) 
taught physicians to differentiate the arhythmias with- 
out the use of the instrument in many cases, so, too, 
it may come to pass that careful comparison of pal- 
patory pulse estimations of pressure with instrumental 
readings of pressure carried out day by day in cases 
of hyper- and hypotension will finally educate the 
physician to make correct deductions in many cases 
without the use of the instrument. There will always 
remain a certain proportion of cases, however, in 
which, owing to various physical factors, an accur- 
ate digital estimation of the systolic blood pressure 
is impossible. A distinguished clinician who has cul- 
tivated this perception to a remarkable degree is 
quoted as saying: "I can estimate the blood pressure 
with the fingers alone quite accurately in about eight 
cases out of ten, but those in which it is of real im- 
portance are always the other two." 

Modern sphygmomanometry will, however, do some- 
thing more than show the variations in the systolic 
blood pressure. Recently, since the introduction of 
the auscultatory or auditory method of using the 
sphygmomanometer, the method of Korotkof, a more 
accurate means of finding the exact diastolic pressure 
has been found than could be had by means of the older 
visual method with the vertical mercury or other 
manometers. 

With accurate data concerning the systolic and 
diastolic blood pressure, we are in a better position to 
interpret results in terms of cardiovascular function 



234 Manual of Vital Function Testing Methods 

than we are by means of the systolic pressure alone. 

In order to fully appreciate just what may be ex- 
pected from such data as the above in the interpretation 
of cardiac function, we must bear in mind of course 
a few simple physiological facts. 

The blood pressure, that is, the systolic blood pres- 
sure, depends mainly upon the contractile powers of 
the heart muscle which enables it to pump the blood 
into the arteries, against the peripheral resistance 
caused by the friction of the blood on the vessel walls. 
The peripheral resistance depends upon the tonicity 
and physical state of the vessel walls. Under normal 
circumstances the elasticity of the coats of the arteries 
provides for a continuous instead of an intermittent 
flow of blood which would be the case if the arteries 
were rigid tubes. 

The systolic or maximum pressure will approximately 
show the actual pressure or work developed by the heart 
at the moment of systole. The diastolic or minimum 
pressure will show the degree of the peripheral re- 
sistance which the heart has been able to overcome 
and which is maintained in the peripheral circulation 
during the time of heart refilling. The difference be- 
tween the highest and the lowest pressures in the larger 
arteries, that is the difference between systolic and 
diastolic pressures, is known as the pulse pressure. The 
pulse pressure, therefore, is the measure of the amount 
of force exerted by the heart in maintaining the blood 
pressure over and above the arterial or peripheral re- 
sistance. To this extent then the pulse pressure is a 
measure of the pumping capacity of the heart and 
hence is of some importance in estimating the state of 
cardiac function. 

Gibson has called attention to the fact that there 
are certain normal arithmetical relations which are 



Tests of Heart Function 235 

discoverable in a study of the three factors — systolic 
pressure, diastolic pressure and pulse pressure. The 
relation of the diastolic pressure to the systolic pres- 
sure is normally as two is to three. The relation of the 
pulse pressure to the systolic pressure is as one is 
to three. If the systolic pressure is 150 the normal 
diastolic pressure will be approximately 100. With 
a systolic pressure of 150, the normal pulse pressure 
will be 50. Of course these figures represent approxi- 
mate and not absolute relations. They are of some 
service in estimating cardiac function because patho- 
logical relations become evident and the presence and 
also to a certain extent, the degree, of cardiac overload 
may be appreciated. 

The normal arteries will apparently withstand a con- 
tinual variation in pressure, that is a pulse pressure of 
35 to 50 mm. of mercury without deterioration. Any 
great increase of the pulse pressure over these figures 
is pathological and at least indicates cardiac overload 
and consequently justifies suspicion that perhaps the 
myocardium may not long succeed in maintaining it. 
The heart manages to do so by undergoing hypertrophy 
and when this has been accomplished the organ may be 
regarded as at least a locus minoris resistentue. 

A quantitative idea of the undue stress may be ob- 
tained by taking the difference between the normal 
and pathological pulse pressure. When this is multi- 
plied by the pulse rate and this by 60 (hour) and again 
by 24 (day) a concrete idea may be gained of the 
enormous excess of energy required to be expended by 
the heart in a day to overcome pathological peripheral 
resistance. 

Such a case, however, may go on and on and we have 
no exact method of predicting just when the break will 
come, with its attendant consequences of cardiac in- 



236 Manual of Vital Function Testing Methods 

sufficiency. As it approaches, however, the diastolic 
pressure will fall, indicating the approaching collapse 
of the cardiovascular mechanism. The larger the 
pulse pressure in relation to the diastolic pressure, the 
greater the strain on the heart will be and the more 
imminent, therefore, is decompensation. A high systolic 
pressure with a relatively low diastolic pressure indi- 
cates, therefore, impending collapse of the heart muscle. 
If after treatment the diastolic pressure rises and the 
pulse pressure falls the indication is that recompensa- 
tion is taking place. 

Technique of Sphygmomanometry. — A brief account 
only of the method of obtaining the systolic and dias- 
tolic blood pressure will be given. A more complete 
description is properly found in texts devoted to the 
subject of blood pressure. The arm band is applied 
to the bared arm above the elbow by placing the broad 
end containing the rubber bag over the region of the 
brachial artery. Wrap the band bandagewise around 
the arm and tuck in the narrow end. Connect up the 
indicator and pump. Apply the sphygmometroscope 
or ausculoscope or stethoscope over the brachial artery 
at the bend of the elbow. Increase the pressure until 
all sounds are gone, then gradually admit air. The 
sounds which are heard are divided into four phases. 
First, a loud clear-cut snapping tone. This is caused 
by the first and the early pulse waves that break 
through the constriction and its beginning repre- 
sents the systolic pressure. Owing to the greater 
sensitiveness of the ear than the fingertip it is usually 
heard some 5 to 10 mm. above the point where the 
radial pulse is first felt. In normal cases, it is said 
to last during the fall of about 14 mm. of pressure. 
Second, a murmur or succession of murmurs lasting 
during the fall of about 20 mm. This phase is not 



Tests of Heart Function 237 

always present and if absent the first and third phases 
merge into one another. Third, a clear tone resembling 
the first, sometimes less well marked but often louder. 
This lasts during a fall of about 5 mm. Fourth, a 
rather sharp transition from the loud to the dull tone 
recently proved to be the time of diastolic pressure. 

As there had been considerable discussion as to 
whether the diastolic pressure corresponded to the be- 
ginning or ending of the fourth phase, Warfield under- 
took its investigation some years ago through a series 
of animal investigations and comparison of cases with 
accurate graphic records. These have been confirmed 
by others and the point now seems to be settled, that 
diastolic pressure coincides with the beginning of the 
fourth phase. 

#. Functional Tests Based on Direct Blood Pressure 

Determinations 

The Cardiac Efficiency Factor of Tiegerstedt. — 
The pulse pressure shows approximately the systolic 
output in energy and the velocity of the blood stream 
will be the product of this energy into the number of 
cardiac cycles (pulse beats) per minute. In other 
words, pulse pressure (PP) times pulse rate (PR) 
will equal velocity of flow. 

Since the interventricular pressure is almost con- 
stant throughout systole, it is evident that the work 
done by the heart is tolerably constant throughout the 
period. The work done by the heart in a unit of time 
will be the product of its maximum energy, systolic 
pressure (SP), multiplied by the pulse rate (PR), mul- 
tiplied by the duration of systole. Since the inter- 
ventricular pressure is constant, the factor duration of 
systole may be eliminated and work done equals product 



238 Manual of Vital Function Testing Methods 

of SP X PR (systolic pressure times pulse rate). 
The reason why interventricular pressure is constant 
is because of the fact that the heart liberates all avail- 
able energy at each contraction. A concrete example 
will readily show how the velocity work ratio is ob- 
tained. If the SP = 130, DP = 85, then PP == 45. 
If PR = 70 then PP 45 X PR 70 = 3,100 (velocity), 
and SP 130 X PR 70 = 9,100 (work), the ratio then 
becomes 

PP 

— = Blood pressure coefficient (Tiegerstedt). 

PP X PR _ Velocity 
SP X PR ~~ Work ' 

This is the velocity work ratio or coefficient of heart 
pumping efficiency. The velocity work relation in this 
example is one to three and this is about the normal 
ratio. Expressed in percentages, it varies normally 
from 25 to 35%. Increase in this ratio may indicate 
cardiac insufficiency. 

The Cardiac Strength, Cardiac Weakness Ratio 
of Goodman and Howell. — These authors have studied 
the duration of the four-tone phases of auscultatory 
blood pressure estimation in a series of normal and 
pathological cases. Their test is based on the ratio 
of these phases to the pulse pressure and to one an- 
other. They set forth their views as follows : 

1. "The first phase or tone phase serves principally 
as an index as to how far the pressure must fall before 
the blood current can be sustained past the obstruction 
in the vessel caused by the cuff at a sufficient velocity 
and for a sufficient duration to produce the murmur. 
Hence the information it affords is of negative rather 
than of positive value. In other words, its normal 



Tests of Heart Function 239 

duration is of no value but an increase or decrease in 
length is of importance. 

2. The second or the murmur phase seems to be espe- 
cially dependent upon cardiac effectiveness, for it is 
in this phase alone that the individual sounds possess 
a distinct element of duration and this protracted 
energy, for so it must be regarded, must evidently come 
from the heart. 

3. The third phase or second tone phase depends 
not alone on cardiac efficiency but also on the character 
of the vessel wall. The more sclerotic the vessel and the 
greater the cardiac hypertrophy, the more favorable 
are the conditions for the production of a clear tone. 

4. As the fourth phase or dull tone may be pro- 
duced by a resilient vessel, receiving a normal pulse 
shock, or by a rigid vessel receiving a weakened shock, 
its interpretation is more difficult. If our assumptions 
are correct it is evident that increases in the second 
and third phases are dependent on cardiac strength 
and circulatory deficiency, while the first and fourth 
phases suffer increase when there is cardiac weakness. 
Furthermore, in dealing with increases or decreases in 
any particular phase it is important to know at the 
expense of what adjacent phase this has occurred. It is 
apparent that an increase in the third phase for example 
at the expense of the second has not the same signifi- 
cance as an increase of this phase at the expense of 
the fourth. In the first instance the unit of cardiac 
strength which we obtain by adding the lengths of the 
second and third phases has not been materially changed 
while in the latter it has been increased. For this rea- 
son we recommend that the sum of the second and 
third phases be compared with the sum of the first and 
fourth phases in order to determine whether the ele- 
ments of force or those of weakness are predominating. 



240 Manual of Vital Function Testmg Methods 

Aside from the value of the persistence of the fourth 
phase in aortic insufficiency little of diagnostic value has 
developed in regard to the length of any individual 
phase. Advantage has been derived, however, from 
studying the changes in the sequence reading, specially 
in decompensating cardiac lesions as the patient im- 
proves or not. In these cases changes in the percent- 
ages of the various phases are not the only significant 
feature but internal peculiarities appear. Or to put 
it another way, sequence readings have a functional 
rather than an organic significance. Our results uni- 
formly show that with decompensation or circulatory 
disturbances of lesser degree, the element of heart weak- 
ness (the sum of the first and fourth phases) progres- 
sively encroaches upon that of heart strength (the sum 
of the second and third phases). The second phase 
appears to be the one which is with most difficulty 
sustained. The fourth phase as weakness gains the 
ascendency, is usually the first to lengthen the element 
of cardiac weakness by its encroachment on the third 
phase, but encroachment of the first phase on the sec- 
ond soon adds its share to the total." 17 

The average duration in mm., the fall of and per- 
centages of the pulse pressure of the different phases 
in normal individuals are: 





mm. 


per cent 


First phase 


14 


81.1 


Second phase 


20 


44.4 


Third phase 


5 


11.1 


Fourth phase 


6 


13.3 



The cardiac strength (second and third phases) : car- 
diac weakness (first and fourth phases) :: 55.5:44.4. 

17 Amer. Jour. Med. Sci., 1911, CXLII, 336. 



Tests of Heart Function 241 

Marked increase of the cardiac weakness factors indi- 
cates cardiac inefficiency. 

Previously to Goodman and Howell's work many 
observers 18 have recognized that the duration of the 
second phase of the auscultatory tones indicated cardiac 
strength. A considerable reduction of its normal per- 
centage of the pulse pressure is therefore taken as a 
test of cardiac insufficiency. 

The Cardiac Overload Factor of Stone, — A pa- 
per on the clinical significance of high and low pulse 
pressure with special reference to cardiac load and 
overload with a report of 170 cases was presented by 
Stone at the meeting of the American Med. Assn. in 
1912. 19 

The ratio of the pulse pressure to the diastolic pres- 
sure representing the load of the heart has since been 
used as a test for cardiac efficiency. Stone says, "the 
pulse pressure measures the energy of the heart in 
systole in excess of the diastolic pressure. For clinical 
purposes it represents the load of the heart. The 
myocardiac load may therefore be expressed by the frac- 

pulse pressure . 

tion -r: — — — and under normal conditions is 

diastolic pressure 

approximately 50%." Anything in excess of this is an 
overload. The average load in these cases was 71, an 
overload of 21%. Naturally in this group of cases 
some did well and some badly. To quote again, "judg- 
ing from this small series of cases it would appear that 
when the overload factor exceeds 50% the patient may 
be in danger of myocardial exhaustion at any time of 
slight overstrain. As a rule the greater the overload 
the greater the danger." That is to say, an overload 

18 Forman, Ztschr. f. diet, und physik. Therap., XIII, 809; 
Fisher: Deutsch. med. Wchnschr., 1908, XXXIV, 1141. 
19 Jour. Amer. Assn., 1913, LXI, 1256. 



242 Manual of Vital Function Testing Methods 

of 50% or more (the pulse pressure equal to or greater 
than the diastolic pressure) indicates cardiac insuf- 
ficiency of a considerable degree with impending de- 
compensation. Whereas an overload of 2,5% would 
seem to indicate a mild degree of insufficiency. 

Swan 20 has recently published a study of the above 
four tests with a series of observations on 40 patho- 
logical cases. His conclusions are as follows: "It 
appears to me legitimate from the study of the cases 
reported to conclude that all four of these factors have 
some value in determining the efficiency of the myocar- 
dium. I am inclined to think at present that the cardiac 
efficiency factor of Tiegerstedt and the percentage of 
the pulse pressure formed by the second phase are the 
most important. A cardiac efficiency factor of 40% 
or over would seem to point out distinct myocardial 
inefficiency. A second phase of 30% or under would 
seem to indicate the same condition. The CS to CW 
(cardiac strength to cardiac weakness) ratio is less 
important I think because it so often cannot be deter- 
mined and again because a small second phase is very 
frequently made up by a large third phase. On the 
other hand, CS : CW ratio in which the CW factor is 
greater than the CS factor is indicative of disturbance 
of the myocardium, functional if not organic. I am in- 
clined to think at present that the overload factor of 
Stone is indicative more of peripheral resistance than of 
myocardial weakness. A cardiac load below 50% as 
determined by this method giving a negative overload 
may have some significance, but it will require further 
study to determine its nature." 

30 Archives Int. Med., 1915, XV, 269. 



Tests of Heart Function 243 



3. Sphygmobolometry 

Sahli has claimed for many years that the attempt 
to estimate the condition of the circulation from 
sphygmomanometric measurements alone is futile, as 
the information derived therefrom is static rather than 
dynamic in character. He therefore believes it would 
be of great service to endeavor to measure not the 
blood-pressures, but the energy of the pulse-wave and 
so, indirectly, the strength of the systole. For this 
purpose he has constructed an instrument, the sphyg- 
mobolometer, which he describes as follows in his ex- 
haustive work on Diagnostic Methods. 21 

As in the measurement of the blood-pressure, the 
Riva-Rocci cuff with the author's quicksilver manome- 
ter is employed. It is necessary that as much as pos- 
sible of the energy of the pulse-wave shall be trans- 
formed into measurable pulsatory movements of the 
mercury in the manometer. To lessen the friction, a 
larger tube (5 mm. bore) is used than in the measure- 
ment of the blood-pressure. This also enables a float to 
be placed in the longer limb of the manometer. In 
order to get a vigorous movement of the mercury a 
somewhat larger cuff should be used (8 cm. broad). 
It is convenient to have the cuff connected with a small 
escape-tube fitted with a stop-cock, so that the pressure 
in the cuff may be diminished at will, and also to have 
a stop-cock interposed between the manometer and the 
bulb. The author employs a four-armed glass tube 
arranged to connect with the cuff, the manometer, the 
bulb, and a capillary escape. The cuff is applied to the 
patient's arm in the usual way, and the pressure grad- 

21 Sahli, H. A treatise on diagnostic methods, edited by N. B. 
Potter, Philadelphia, 1911. 



244 Manual of Vital Function Testing Methods 

ually increased; at each increase of pressure, commu- 
nication between the bulb and the cuff is temporarily 
shut off, either by using a stop-cock, as above, or by 
pinching the tube. When a certain pressure is ob- 
tained, the mercury in the manometer will be seen to 
oscillate up and down. Sometimes these oscillations 
are visible when communication with the bulb is open, 
but generally they are plainer when the bulb is shut off. 
Some investigators have employed these oscillations to 
determine the pressure, e.g., von Recklinghausen and 
Mosso. They obviously arise from the energy of the 
pulse-wave, which, at a certain medium point of com- 
pression of the brachial artery, is carried through the 
cuff to the manometer in sufficient strength to set the 
quicksilver in vibration. If the bulb is connected, the 
amount of air it contains, of course, materially re- 
duces or even hides the periodic increase of pressure 
in the air between the pulse and the manometer. The 
smaller the caliber of the connecting tube and the 
more rigid its walls, the stronger, of course, are the 
pulsations. The point of pressure at which the maxi- 
mum vibrations are set up in the manometer is found 
not to correspond to that of the maximum nor to that 
of the minimum arterial blood-pressure, but to lie some- 
where between these, not, however, at their exact mean. 
The author's proposed use of mercury vibrations has 
nothing in common with conclusions as to the state 
of the blood-pressure; nor is it related to the at- 
tempts of Riva-Rocci and others to employ these vibra- 
tions in the determination of the lateral arterial pres- 
sure. 

Sphygmobolometry is entirely different; it aims to 
determine, not the pressure, but the work performed 
by the pulse. The vital energy of the pulse-wave, which 
is transferred to the cuff, is what sets the column of 



Tests of Heart Function 245 

mercury in vibration. If that point of compression be 
selected where these vibrations are at a maximum, i.e., 
where the transformation of energy is most nearly com- 
plete, the work done by the pulse-wave can be calcu- 
lated after reading off the maximum height of the mer- 
cury column. Obviously, however, such conclusions 
hold good only for one type of apparatus, the results 
being influenced by the breadth of the cuff, the volume 
of air-space enclosed, the quality of the rubber, etc. 
In his original communication the author attempted to 
announce absolute results concerning the work done 
by the pulse-wave, but it must be understood that the 
values thus obtained were always to be multiplied by 
the constant of the particular instrument. If, how- 
ever, instruments of the same construction are always 
employed, as is desirable for clinical work, this con- 
stant may be ignored, and at least relatively correct 
and comparable results be obtained. 

One other important point must be noted. Since the 
maximum excursions of the mercury do not occur at the 
moment when the manometer shows the maximum 
pressure, it is obvious that a part of the pulse-wave 
escapes under the cuff. The author has shown that 
this fraction is variable, depending upon the shape of 
the pulse-wave. In order, then, to secure constant 
conditions the wave must be prevented from escaping 
in part under the cuff, and as far as possible be forced 
to exert its energy entirely in the direction of the ma- 
nometer. This is accomplished by first winding an Es- 
march bandage around the arm, either at the elbow 
or between it and the cuff, tightly enough to obliterate 
the radial pulse. This device to a certain extent con- 
verts that portion of the brachial artery which extends 
to the lower edge of the cuff into a cul de sac from the 
aorta (a sort of sphygmoscope). 



246 Manual of Vital Function Testing Methods 

If, now, the energy of the pulsation be noted at this 
arterial stump and be measured by the excursions of 
the mercury, we approximately estimate the energy of 
the aortic pulse. The instantaneous compression of 
the venous trunks, caused by the pressure of the cuff, 
subjects not only the small veins and the arteries, but 
also the capillaries, to the arterial pressure, and they 
all pulsate with it. This naturally facilitates the com- 
pleteness of the transference of energy to the mercury, 
since not only the small volume of the arteries, but the 
whole arm stump takes part in the variations of vol- 
ume. The mechanical conditions of the test are the 
same in every case; hence it seems proper to assume 
that practically constant and comparable estimates 
are obtained, provided, of course, that the pressure of 
the cuff be adjusted to secure maximum excursions. In 
making use of this test clinically we must evidently 
avoid any factor which could artificially alter the en- 
ergy of the pulse-wave, e.g., pain from an overtight 
Esmarch bandage, such as to affect the heart action. 
Caution, experience, and quickness in performing the 
experiment will, however, usually eliminate this par- 
ticular factor. 

It remains, therefore, merely to measure the extent 
of the excursions of the mercury, and to make the cal- 
culations from the data obtained. For the measure- 
ment of the excursions of the mercury, it is sufficient 
for purely practical clinical or demonstration purposes 
merely to note with the eye the highest point on the 
manometric scale reached by the mercury. The dis- 
tance must, however, be read to fractions of a milli- 
meter. For this purpose a scale giving fifths of a mil- 
limeter may be fastened alongside the mercury tube, 
and by means of a suitable telescope the extent of the 
excursions be read off from a distance. For more 



Tests of Heart Function 247 

exact purposes a graphic method of recording the re- 
sults is preferable. The author uses a float riding di- 
rectly on the mercury and carrying a writing point, 
which records the excursions vertically, and without 
magnification. It writes on a piece of smoked paper, 
12 cm. high, fixed in a vertical frame attached to the 
stand of the manometer near its base. By turning a 
crank the paper and its frame can be moved horizon- 
tally about 6 cm. The manometer is so heavy at the 
base that this can be done without shaking the instru- 
ment. As the writing apparatus, for the sake of sta- 
bility, must be placed as near the base of the instru- 
ment as possible, it becomes necessary to devise some 
means for transferring the movements of the float from 
the top of the manometer tube to the bottom. For this 
purpose a thread is attached to the arm of the float. 
From it hangs a thin metal wire, bent at its end into a 
horizontal writing point. This wire is guided by being 
passed through a glass tube, which is fastened to the 
instrument. The proper amount of friction can be at- 
tained by adjusting this glass tube and a greater or 
less torsion of the thread. 

The technic of the procedure is as follows : the cuff 
is attached to the upper arm and connected with the 
apparatus by the 4-armed glass tube. The brachial 
artery distal to the cuff is compressed by an Esmarch 
bandage until the radial pulse disappears. By com- 
pression of the bulb the column of mercury with its 
float is made to assume different heights. After the 
proper adjustment of the needle to the smoked paper 
has been made, bolometric curves are taken for the 
different pressures, the connection with the bulb being 
each time cut off. A slow movement of the paper is 
sufficient, because the method is concerned with the 
height, and not the form, of the curve. Hence a large 



248 Manual of Vital Function Testing Methods 

series of pulse-waves can be recorded on one line of a 
paper 6 cm. wide, and by moving the smoked paper 
back and forth curves for the different pressure heights 
may be traced one below the other. With such long 
tracings we can often note distinct Traube's waves cor- 
responding to a periodic increase and decrease in the 
mercury excursions. In such instances the cardiac 
work, and not alone the blood-pressure, is evidently in- 
creased and decreased. The zero pressure line is given 
the position of the writing point when the manometer 
is at rest ; the hight of pressure corresponding to each 
curve can then be easily determined by measuring in 
millimeters the distance from the zero line to a hori- 
zontal drawn later to intersect the points half-way be- 
tween the tip and foot of the waves. Since the manom- 
eter is constructed with two limbs, this distance must 
be doubled. It is self-evident that this doubling only 
applies to measuring the mean position of the mercury, 
not the height of an individual wave. For reckoning 
the work done by the pulse under observation we se- 
lect that curve which shows the greatest excursions, 
since at that moment the transmission of energy was 
most nearly complete. 

It remains to consider the clinical value of the results 
obtained by sphygmobolometry. It is obvious that we 
are computing not the entire energy of the heart, but 
only that fraction which acts upon the portion of the 
arm stump obstructed by the Esmarch bandage and 
corresponding to the surface of the cuff. The muscu- 
lar development of the arm would naturally affect this 
fraction to some extent. But in healthy individuals 
the differences between the results are found to be so 
small, and in pathologic conditions of the heart so 
great, that the author believes it possible to consider 
the result found as an approximately constant fraction 



Tests of Heart Function 249 

of the total work done by the heart in each case. Con- 
clusions may, therefore, be drawn concerning the en- 
tire amount of cardiac work — a result impossible by 
any previous method. The objection may be made that 
we are measuring simply the wave energy in the artery, 
and taking no account of the current energy. The au- 
thor, however, believes such a criticism to be entirely 
unwarranted. For, if we measure the wave energy in 
a peripherally closed artery, we are really measuring 
the entire energy from the heart exhibited at that 
point, because the current at the periphery through 
the capillaries, which determines the amount of the cir- 
culation, is entirely due to this wave energy. The 
pressure in the capillaries arises wholly from the change 
of kinetic wave energy into potential pressure energy. 
This is illustrated by a fact easily shown by the sphyg- 
mograph. If even a single pulse be lost, the minimal 
pressure, i.e., the base of the curve, instantly falls. 
The arterial pulse is therefore to be conceived as a kind 
of peripheral heart, working not automatically, to be 
sure, but by its elasticity, or, to a certain extent, by its 
resiliency. This conception of the pulse is set forth 
and defended in the author's work on the absolute 
sphygmogram. He considers it a most important one, 
and exceedingly fruitful in any study of the dynamics 
of the circulation. It at once makes clear the signifi- 
cance of sphygmobolometry. If one assume, then, that 
by the sphygmobolometer he measures an approxi- 
mately constant fraction of the entire heart energy (its 
exact value depending upon the constant of the instru- 
ment), it is possible to get at least approximately rela- 
tive values for the active circulation. 

It should be added that this procedure corresponds 
to the old-fashioned method of feeling the pulse, which 
sought to estimate the force of the pulse-wave rather 



250 Manual of Vital Function Testing Methods 

than the height of the blood-pressure. This method 
has been entirely neglected of late on account of the 
disproportionate modern insistence on the static con- 
ception of the circulation, and yet this method of feel- 
ing the pulse is perhaps the most practically useful one, 
since it focuses the attention on the work done by the 
pulse-wave without regard to the blood-pressure. It 
appreciates the pulse energy, which the more exact 
method of bolometry records and measures. This 
method measures, not the amount of work which the 
heart is capable of performing under increased de- 
mand, but the amount which it actually performs at a 
given moment, e.g., the performance of the heart and 
the size of the circulation in a healthy individual at rest 
may appear very small ; and yet this does not preclude 
such a heart's capacity for a very much greater task 
under the stimulus of vigorous muscular work. Hence 
in a given case the functional examination may have 
to be supplemented in this respect by noting the altera- 
tion of the sphygmobologram after making an in- 
creased demand on the heart, e.g., lifting a weight with 
the free arm. With a heart capable potentially the 
work (W) (measured sphygmobolometrically) in- 
creases materially; with serious cardiac insufficiency, 
on the contrary, this work does not increase and may 
even decrease. 

Sahli has more recently devised a simplified pocket 
sphygmobolometer which he demonstrated at the 
XVIIth International Congress of Medicine at London 
in 1913, and which is described by N. B. Potter in the 
Journal of the American Medical Association for April 
9, 1913. In this the graphic method of recording the 
maximal excursions is replaced by a visual method with 
a kerosene index in a blind compressed air manometer, 
connected with the recording manometer, and direct 



Tests of Heart Function 251 

compression of the radial artery by a small rubber bag 
and graduated air syringe is substituted for the cir- 
cular compression of the brachial artery. As his origi- 
nal apparatus was rather cumbersome this simplified 
instrument will bespeak a wider usage of this impor- 
tant method of testing cardiac function. 

Ji*. SpTiygmobolograpTiy 

At the XVIIth International Congress of Medicine 
Sahli described a method for using Jaquet's sphygmo- 
graph for measuring the energy or working power of 
the pulse, which he termed sphygmobolography. His 
description is as follows : 22 

The possibility of this results from the following 
simple consideration. The mechanical effect of a force 
is known to be calculated as the product of force (or 
weight) and distance. In sphygmography the spring 
plays the part of the weight, whereas the excursion of 
the recording point represents the distance. So by 
multiplication of these two values expressed in grammes 
and centimeters we get the mechanical effect or the 
energy of a given sphygmogram in gramme-centimeters. 

It is true that there exists the theoretical difficulty 
that the weight or force changes continually during 
the taking of a sphygmogram, because by the progres- 
sive elevation of the sphygmogram the tension of the 
spring increases. However, I was able to prove that 
in Jaquet's new sphygmograph the modulus of elas- 
ticity of the spring is nearly constant, so that the in- 
crease of the tension of the spring is nearly propor- 
tional to the excursion and rises in the form of a 
straight line. Hence for the calculation of the mechan- 

22 Sahli, H., in Transactions of XXVIIth International Congress 
of Medicine, London, 1913. 



252 Manual of Vital Function Testing Methods 

ical effect of the pulse we can take as the force (or 
weight) the arithmetical mean of the initial and the 
terminal tension of the spring. Thus if we know the 
amount of the spring-tension at the foot and at the 
summit of the sphygmogram in absolute measure (in 
grammes) the sphygmobolometric utilization of the 
sphygmogram (that is what I call sphygmobologra- 
phy) presents no kind of difficulty. 

To carry out the determination easily I have sup- 
plied Jaquet's sphygmograph with a little modification 
which can be adapted easily. This modification con- 
sists essentially in the adaptation of a recorder of 
abscissae. This is composed of nine little wheels press- 
ing the blackened strip of paper against the cylinder 
of the moving mechanism. The distances of these ab- 
scissae are chosen so as to correspond to an excursion 
of the recording point of 0.005 cm. 

These abscissae have a double purpose. They serve 
to calibrate the tension of the spring for every level of 
the sphygmogram in absolute measure (grammes), and 
at the same time to show directly on the sphygmogram 
the travel of the recording point in centimeters. The 
maker adds to every instrument thus modified a cali- 
brating table, marking for every position of the tension 
mechanism and for every abscissa the spring-pressure 
in absolute measure, that is in grammes. 

So to calculate any given sphygmogram sphygmo- 
bolometrically we have only to measure the excursion of 
the recording point by the height of the sphygmogram 
with the aid of the calibrated abscissae and to take 
from the said table the tension in grammes for the ab- 
scissa half-way between the foot and the summit of the 
sphygmogram. The multiplication of the two values 
will give us the amount of the energy or mechanical ef- 
fect of the pulse. 



Tests of Heart Function 253 

Naturally one must bear in mind that just as in 
pneumatic sphygmobolometry, the optimum transmis- 
sion of the pulse-energy to the recording apparatus is 
only obtained by one certain optimal counter-pressure 
on the artery. Thus for obtaining comparable values 
it is necessary in each case to take on one strip of 
paper the whole series of sphygmograms with all the 
different spring-pressures which give curves, and to 
choose that curve which gives, on calculation, the great- 
est energy value. 

Example: For three successively taken sphygmo- 
grams I obtained the values: 

12 3 

Tension = 135.5 gm. Tension = 142 gm. Tension = 168 gm. 

Excursion = 0.0125 cm. Excursion = 0.015 cm. Excursion =0.01 cm. 

Energy =1.7g. cm. Energy = 2.13 g. cm. Energy =1.68g. cm. 

Thus the real energy would be 2.13 g. cm. 

To apply this method to functional testing of the 
heart, it must of course be employed before and after 
exercise, the energy in the latter case being greater in 
a healthy heart, and showing no increase or a decrease 
proportional to the functional damage in an unsound 
heart. 

5. Energometry — Dynamic Diagrams 

Christen has advocated the dynamic diagnosis of the 
pulse, along lines similar to, though differing somewhat 
from, those of Sahli. He gives a detailed discussion 
of his methods, with elaborate mathematical proofs in 
a recent monograph. 23 The following account is taken 
from a simplified exposition which he prepared for the 
general practitioner: 24 

23 Christen, Th. Die dynamische pulsuntersuchung, Leipzig, 1914. 

24 Christen, Th. Dynamic diagrams of the pulse. International 
Clinics, Philadelphia, 1911. 



254 Manual of Vital Function Testing Methods 

The Hypothesis. — The old-fashioned palpation of 
the pulse tells us much more about the condition of the 
circulation than does the sphygmogram, in spite of its 
seemingly higher scientific character. In the clinical 
sphygmogram there is no exact relation between the 
ordinates and the pressures. We do not even know 
where to trace the level of the pressure zero. Even 
if there were such a relation, sphygmography would 
still not be a dynamic method, as in dynamics we do 
not have to study only the temporal variations of the 
forces, but essentially the effect of these forces. These 
two statements sufficiently explain the failure of the 
clinical sphygmogram. There are two dynamic dia- 
grams of the pulse that may be determined on a mathe- 
matically exact manner. They are the graphic expres- 
sion of clinical experiments based upon the following 
two questions : 

a. What is the systolic increase of volume of the 
arteries covered by a pneumatic cuff at a given pres- 
sure ? 

b. What is the amount of mechanical energy re- 
quired for this movement? These dynamic dia- 
grams, called stowing curves, are characteristic of the 
behavior of the pulse against a stowing pressure. They 
depend on the volume of air within the cuff as little as 
they do on the elasticity of the cuff and the soft parts. 
They depend only on the breadth of the cuff. We 
therefore have to compare stowing curves derived from 
experiments with cuffs of the same breadth. The ex- 
clusive arguing with the notion of pressure and its 
temporal variations will never be able to exhaust the 
question of diagnosis of the pulse, for the mechanics 
of the pulse contain essentially dynamic problems, more 
than any other province of physiology. The stowing 
curves (dynamic diagrams) replace the palpation of 



Tests of Heart Function 255 

the pulse by an exact method, because they answer 
the same questions that does palpation, informing us 
about the filling and the intensity of the pulse. They 
are to inaugurate a new epoch of clinical research, be- 
cause for the first time there has been established here 
a correct dynamical principle. 

The Method. — The energometer consists of a close 
fitting cuff, 9 cm. wide, connected with an inflating 
bulb, a special manometer and a graduated air syringe. 
The cuff is applied to the patient's arm or the calf 
of the leg. The latter is preferred, owing to the pos- 
sibility of greater muscular relaxation and absence of 
disagreeable sensations. 

In order to find out the value of the systolic increase 
of volume, i.e., the volume of blood, the pushing forth 
of which against the pressure of the cuff produces the 
oscillations observed on the manometer, we make use of 
a syringe, whose piston has to be pushed in up to the 
point where the oscillations have been displaced about 
its own amplitude. 

Example: We observe on the manometer oscilla- 
tions between the limits 170 and 176. Pushing in the 
piston of the syringe we increase the pressure within 
the cuff, elevating both limits of these oscillations. We 
do this in such a manner as to just reach the point 
where 176 has become the lower limit of the oscillations, 
having been heretofore its upper limit. Thus we are 
sure that the volume of the piston, which is read off 
on its own scale, must be that incompressible volume 
which brought under the manchette increases the pres- 
sure within it from 170 to 176. Two incompressible 
volumes, which, forced into the same gas-room, pro- 
duce the same increase of pressure within it, must be 
equal. Therefore, the volume read off on the piston 
must be equal to the systolic increase of volume of the 



256 Manual of Vital Function Testing Methods 

artery (or arteries) that is covered by the inflated man- 
chette. 

Suppose that we read a volume of 0.7 centimeter, 
then we know that the mechanical energy required for 
the same increase of volume — the mean pressure being 
173 gr./cm — must have the value : 

gr. 

173 X 0.7 cm. = 121 gr. cm. 

cm. 

In this way we find for every pressure (P) a volume 
(V) and an energy (E), the relation between which is 

e = p v 

Repeating this experiment at different pressures we 
get a series of pressure volumes and energies, which we 
arrange in the following manner : 

Example: 



Pressure 


Volume 


Energ 


80 


0.1 


8 


120 


0.3 


36 


140 


0.55 


77 


165 


0.9 


149 


190 


1.2 


228 


210 


1.2 


252 


225 


0.9 


203 


240 


0.4 


96 


250 


0.2 


50 



The Diagrams. — In order to give a clearer idea of 
the relation between these quantities, viz., pressure, vol- 
ume, and energy, we plot two curves, which represent 
the volumes or the energies as functions of the pressure. 
Therefore, in our graphic method we have to plot the 
pressure as abscissas and the volumes or the energies 
as ordinates. 

Functional Diagnosis. — The study of the blood cir- 
culation under different conditions, as after any thera- 
peutic procedure whatsoever, medicines, cures, or after 
a given dosage of labor, is done in the most exact way 



Tests of Heart Function 257 

by the dynamic diagram. Here we are able to show 
now a rise or fall of the summit, now a displacing to- 
wards a higher or a lower pressure, as in a sharpen- 
ing or flattening of the curves. 

The methods of Sahli and of Christen, introducing 
as they do the underlying principles of dynamics into 
the study of the pulse and the systolic output of the 
heart, are of great promise, and have already shown 
their value in clinical work when applied to functional 
testing of the efficiency of the cardiac muscle. 

6. Rontgenoscopy and Rontgenography as Indices 
of Cardiac Function 

The form, position and movements of the heart as a 
whole and its different chambers, also the great vessels 
at its base, can be very successfully examined by the 
X-ray. For several reasons we need only touch upon 
this interesting and remarkable method of cardiac ex- 
amination. In the first place, the application of the 
X-ray to the study of the heart concerns more par- 
ticularly the examination of the organ from a diag- 
nostic and anatomical point of view. From this stand- 
point it constitutes a valuable addition to the older 
methods of heart exploration. It cannot be said, how- 
ever, that a Rontgen ray examination sheds much 
light upon the question of cardiac function. Its chief 
use is to denote changes in the shape of the organ, 
hypertrophy and dilatation of its cavities, aneurysm, 
pericardial effusions, etc. By orthodiagraphy, the posi- 
tion and topography of the heart can be accurately 
delineated. But neither ordinary Rontgenoscopy nor 
orthodiagraphy of the heart sheds much light upon the 
problem of estimating the exact efficiency of the cardiac 
function. 



258 Manual of Vital Function Testing Methods 

7. Sphygmocardiography and Electrocardiography; 
Their Relation to Cardiac Functional Capacity 

In many text books the phrase, functional disease of 
the heart, is often used synonymously for pulse irregu- 
larity. The phrase, cardiac function, is used in an 
entirely different sense here. Cardiac function, so far 
as the present discussion is concerned, relates to the 
capacity of the heart to perform its work, with the 
adequate maintenance of its reserve. An irregularity 
of the cardiac rhythm does not necessarily mean any 
serious deterioration of function. For example, an 
individual may have a sinus arhythmia or an occasional 
premature contraction and possess an absolutely 
normal cardiac reserve. 

On the other hand, the discovery of certain other 
types of irregular rhythm always indicates a serious 
disturbance of heart function. The presence of true 
heart block, for example, denotes a lesion of the con- 
ducting system and hence a deterioration of function. 
The same may be said of auricular fibrillation and to 
an even greater extent of pulsus alternans. 

But the detection and identification of irregularities 
in the cardiac rhythm is a part of the general semi- 
ological investigation of that organ and while of great 
importance to the clinician who is examining a case 
for heart disease, does not properly come within the 
scope of an investigation into the methods of estimating 
cardiac function. 

The study of cardiosphygmography and electro- 
cardiography has undergone a tremendous develop- 
ment in recent years. The names of Marey, Franck, 
Gaskell, Engelmann, Wenkebach, Herring, MacKenzie, 
Lewis, Erlanger, His and many others are prominently 
identified with the former and those of Waller, Ein- 



Tests of Heart Function 259 

thoven, Kraus, Nicolai, Edelmann and others with the 
latter. 

The recognition of nearly all the varieties of arhyth- 
mia may be determined by the skilled clinician without 
the use of any technical apparatus. Unfortunately, 
this is not always the case and there are types of irregu- 
larity of the heart rhythm which can only be posi- 
tively recognized by the use of some form of instru- 
mental registration. Pulsus alternans is the best ex- 
ample of this fact. This variety of arhythmia cannot 
be recognized with certainty without pulse tracings. 
Its importance from a prognostic standpoint, as Lewis 
points out, is extremely great. This fact alone will al- 
ways make the polygraphic study of the pulse a matter 
of necessity in all cases in which there is a suspicion 
that pulsus alternans may be present. 

The ordinary methods of examining the heart, em- 
ployed in clinical diagnosis, are exceedingly well adapted 
to disclose diseases of the organ. By inspection, palpa- 
tion, percussion and auscultation, properly performed, 
not only can it be determined that disease of the heart 
is present, but the precise location and often the nature 
of the lesion can be made out. As Cabot has well 
expressed it, "we are very well satisfied with the ordi- 
nary methods of examination, when we find something 
such as valvular disease, obstructions, accumulations 
and degenerations. But in many cases in which we 
fear that the heart is diseased and its functional power 
diminished, the ordinary methods of investigation do 
not show anything. Even the more technical and re- 
fined instrumental methods are negative only too often 
in such cases. The heart has passed a good physical 
examination and yet may be insufficient. We desire to 
know what the heart can do, what is the condition of 
its reserve. The necessity of supplemental methods 



260 Manual of Vital Function Testing Methods 

becomes manifest. This is the proper field for experi- 
mental inquiry into the heart function. It is here 
that the functional tests become especially useful. We 
give the heart some work to do and see how it reacts, 
how fast it tires, how slowly it recuperates. We sub- 
ject the patient to extra effort and note the general 
symptoms produced, particularly dyspnoea. We pro- 
ceed to a careful analysis of the history of our patient 
with respect to his subjective reaction to all of his 
environment. Already we are working with problems 
of cardiac function in a fundamental manner." 



GENEEAL CONCLUSIONS AS TO TESTS FOR CARDIAC 

FUNCTION 

Hirschfelder, speaking upon the importance of func- 
tional tests or studies in borderland cases between func- 
tional sufficiency and cardiac failure, emphasizes the 
importance of careful observation and says: "It must 
be admitted that in order to be decisive, all tests have 
to be pushed to a point at which the appearance, sensa- 
tions and signs of the patient are in themselves per- 
fectly characteristic of cardiac insufficiency and at 
which, for diagnostic purposes, a little common sense 
observation is at least as unambiguous as observation 
with elaborate apparatus. This does not mean that 
exercise tests are unimportant. On the contrary, they 
are of the greatest value and no change in the patient's 
mode of living during convalescence or during after 
life should be undertaken without them. 

"But their importance depends more upon the care 
with which the physician watches the general appear- 
ance and condition of the patient, the rapidity with 
which he recovers from the exercise, his general condi- 
tion and whether nervousness, irritability, cough or in- 



Tests of Heart Function 261 

somnia have set in during the 24 hours following it, 
than in the numerical changes which occur at the mo- 
ment of exercise. The symptoms to be looked for as 
evidence of overwork are well known. These are subtler 
manifestations resulting from smaller changes than may 
be detected by even the most refined observation by 
mechanical methods and which are less easily masked 
by ambiguities. 

"Moreover, it must be realized that any one form 
of exercise furnishes data which may depend as much 
upon the condition of the skeletal muscles as upon the 
heart. The blacksmith with a diseased heart may be 
able to do more work than the bookkeeper with neuras- 
thenia and yet under the conditions in which he lives 
even if not under the strength test arranged for the 
average man, the blacksmith's heart may be failing. 
In diagnosis, prognosis and therapy the testing of func- 
tional insufficiency is a matter of sociology as well as 
physiology. The important question is not what the 
person can do in a gymnasium, but what he can do 
and what he cannot do in everyday life. Each man 
must be fit for his own mode of life or must be made 
to change it. His cardiac power must be studied with 
reference to that mode of life rather than with refer- 
ence to a rigid scheme." 25 
25 Diseases of Heart and Aorta, Phila., 1913, 199. 



CHAPTER V 

THE DUCTLESS GLANDS AND VEGETATIVE 
NERVOUS SYSTEM 

GENERAL CONSIDERATIONS 

The clinical examination of function of the endoc- 
rinous glands is a subject capable of great future 
growth. Only the first steps have so far been taken in 
developing this mine of hidden riches. To the physi- 
ologist, pathologist and clinician the subject offers a 
fertile and tempting field of investigation. 

In the following account of the functional diagnosis 
of the endocrinopathies but little can be given of the 
enormous mass of experimental material, and, as 
Barker * has said, "the greater mass of theories" pro- 
pounded, concerning the physiology, semiology, pathol- 
ogy and interrelations of the glands of internal secre- 
tion. These subjects with complete bibliographic and 
historic references can be found in the classical works 
of Biedl, 2 Vincent, 3 Falta, 4 Levi-Rothschild, 5 Paton, 6 
Sajous 7 and others. 

In these great works little or nothing can be found 

Southern Med. Jour., 1914, VII, 1. 

2 Internal Secretary Organs, London, 1912, Bale Danielsson 
(Trans, from German). 
'Ductless Glands, London, 1912, Arnold. 
4 Erkrankungen der Blutdrusen, Wien, 1913. 
8 Endocrinologie, Paris, 1911, Dion. 
6 Internal Secretions, Phila., 1911, Davis. 
1 Regulators of Metabolism, London, 1913, Macmillan. 

262 



Ductless Glands 263 

concerning the important question of functional diag- 
nosis. The material that has been evolved concerning 
the investigation of function of the ductless glands or 
glands of internal secretion is not only scant but scat- 
tered widely in the literature from whence so far as we 
know it has never been gathered. Not a single article 
devoted to the general question of the functional diag- 
nosis of the endocrine glands exists in the whole medical 
literature. In isolated instances where the subject of 
functional diagnosis is mentioned, upon investigation 
it is found that the question is treated upon an almost 
purely semiological basis. The semiological method of 
diagnosis of diseases of the ductless glands has there- 
fore reached a higher degree of development than the 
functional method, among clinicians up to the present 
time. Notwithstanding all this, it is admittedly true 
that the clinician is much in need of functional tests, to 
enable him to discover the various endocrinopathies in 
their latent stages, or, as the French say, in the -forme 
fruste, when the symptomatic picture may be incomplete 
or confusing. Therefore, while at the present time it 
cannot be said that satisfactory chemical or biological 
functional tests have been discovered, capable of dis- 
closing with certainty the existence of latent disease of 
the thyroid, parathyroid, thymus, pituitary or adrenal 
organs, nevertheless some advance has been made in this 
direction and the great need for such tests, in this im- 
portant tho subtle field of clinical medicine, will always 
constitute a sufficient inspiration for further discovery. 
As will be developed, the principal tests which have 
been devised up to the present time with the object of 
testing endocrinous function, relate to the thyroid 
gland and particularly with that aspect of thyroidop- 
athy which is connected with an increased activity of 
the gland. Function testing of the adrenals has received 



264 Manual of Vital Function Testing Methods 

some attention and development. The other ductless 
glands remain so far a terra incognita to the functional 
method. When we stop to consider how much remains 
to be known concerning the functions and interrelations 
of the glands of internal secretions, the fact will not 
be surprising that the subject of functional diagnosis 
of their diseases has not received a greater develop- 
ment. 

Regarding the ductless glands as a whole, we cannot 
fail to be impressed with their intimate relation to the 
processes of body metabolism. The organs of internal 
secretion or ductless glands (blutdrusen) are important 
regulators of metabolic processes. It is agreed that the 
pancreas normally inhibits carbohydrate metabolism 
and that on the other hand the thyroid and suprarenals 
normally increase carbohydrate metabolism. The thy- 
roid has an important effect upon proteid metabolism 
not shared by the other glands. Increased function of 
the thyroid is accompanied by increased proteid metab- 
olism while hypofunction of the thyroid produces a dim- 
inution of proteid exchanges. The parathyroids and 
thymus are intimately concerned with normal calcium 
metabolism but their exact relation to this process is 
unknown. The gas exchanges of the organism are also 
fundamentally controlled by the ductless glands. In 
hyperthyreosis there is an increase, and in myxedema a 
decrease, of the oxygen absorption and C0 2 exchange. 

These facts have formed the basis of certain experi- 
mental methods of determining the functional capacity 
of the ductless glands and were it not for the fact that 
the performance of metabolic experiments is so com- 
plex and requires so extensive an instrumental equip- 
ment, the examination of these processes as aids to the 
functional diagnosis of the endocrinopathies would have 
a much wider application. 



The Ductless Glands 265 

I. THE THYROID GLAXD 

1. Tests of Functional Activity 

Without entering debatable ground, it may be con- 
fidently asserted that there are certain facts regarding 
the physiology and pathology of the thyroid gland 
which are universally admitted. It is clear, for in- 
stance, that the thyroid is of great importance in the 
economy of the human organism, and that certain 
lesions of this gland give rise to symptoms which when 
they are outspoken may be definitely correlated with 
thyroid disease. 

However, despite all the work, experimental and 
clinical, which has been done upon this gland, there is 
even now no absolute unanimity of opinion of the pre- 
cise function or functions of the thyroid. The thyroid 
function is probably not simple but complex. As in 
the case of the other ductless glands, many physicians 
feel convinced that there is an antitoxic function of the 
thyroid, which consists in collecting exogenous iodine 
and in some mysterious and unknown way neutralizing 
certain hypothetical products of intermediary metab- 
olism. Naturally this idea is a pure speculation and 
has been arrived at by indirect reasoning. The most 
usually accepted theory of thyroid function is, how- 
ever, that the thyroid manufactures an internal secre- 
tion, possibly an iodine proteid, which is essential to 
the proper growth and normal metabolism of the entire 
body. Baumann 8 made an epochal discovery in 1895 
when he showed that the thyroid gland contains iodine. 
Although speculation and investigation have since been 
rife in respect to this discovery, its precise meaning 
is yet unknown. 

The vast amount of work which has been done upon 
8 Zeitsch. f. physiol. Chem., 1895, XXI, 319. 



266 Manual of Vital Function Testing Methods 

experimental extirpation of the thyroid can only be 
mentioned. If the thyroids are removed from young 
animals, growth is retarded. Total extirpation of the 
thyroids in human beings is well known to be followed 
by serious symptoms, the so-called cachexia strumipriva. 
If the individual is young there will be retarded growth, 
faulty ossification, mental and metabolic enfeeblement. 
Similar symptoms are seen in children with congenital 
thyroid aplasia. In human beings who are deprived of 
their thyroids, a phenomenon appears which is not seen 
in lower animals, namely myxedema. 

Spontaneous myxedema also occurs in the adult 
human being as a result of thyroid insufficiency — the 
so-called Gull's 9 disease. Murray 10 discovered that 
the administration of thyroid extract will eliminate the 
symptoms of myxedema. 

If thyroid substance be fed to normal animals, symp- 
toms will develop which are similar to those that occur 
in Graves' or Basedow's disease in the human subject 
and are supposed to be due to a hyperthyreosis or 
hyperthyroidization — in other words, an increase of 
function of the thyroid. 

This brings us to the important induction that in 
the human subject we may have two different or rather 
two opposite pathological states to consider in respect 
to the thyroid gland and its functions, namely A. a 
hyperthyreosis and B. a hypothyreosis. In the well 
developed state these two symptom groups constitute 
definite and tangible clinical syndromes. 

#. Ht/perf unction of the Thyroid Gland 

To the syndrome of hyperthyreosis, the name of 
Graves' or Basedow's disease is attached. The symp- 
• Trans. Clin. Soc, London, 1874, VII, 180. 
"Brit. Med. Jour., 1891, 796. 



The Ductless Glands 267 

toms of hyperthyreosis may be placed in the following 
categories: 1, enlargement of the gland; 2, signs of 
heightened excitability of the vegetative or sympathetic 
nervous system; 3, signs of secondary or concomitant 
disturbances in other endocrinous glands ; 4, symptoms 
of profound disturbance, usually of excess metabolism ; 

5, a variety of disorders of the central nervous system ; 

6, a peculiar picture in the blood (leucopenia with 
lymphocytosis ) . 

Naturally in this review of functional diagnosis we 
cannot go into a detailed account of the semiological 
data which might be collected under each of the above 
headings. It is interesting to observe that the symp- 
toms of Graves' disease which come under the category 
of the vegetative nervous system involve both the auto- 
nomic and sympathetic portions of that system. The 
autonomic and sympathetic innervations are both in- 
volved to a certain extent in every case, but in one, the 
former, and in another case, the latter, system will be 
predominantly affected. The eye, heart, blood vessels, 
skin, digestive, respiratory and urogenital apparatus 
are all supplied with innervations of both kinds, usually 
reciprocally or antagonistically, and consequently in 
Graves' disease there are symptoms referable to disturb- 
ances in sympathetic or autonomic innervations in sev- 
eral or in all these different organs. We shall not enu- 
merate all the various symptoms of Graves' disease, 
since such an enumeration will be readily found in books 
or articles dealing with the semiology of this condition. 
Whenever a sufficient number of these symptoms can be 
found in a given case the diagnosis of Basedow's disease 
can be readily made and a quantitative idea of the se- 
verity of the case may be gained by the actual number 
or the seriousness of the symptoms. In other words, 
when the classical semiology of Graves' disease is pres- 



268 Manual of Vital Function Testing Methods 

ent, naturally no functional tests will be needed. 

A striking phenomenon of Graves' disease is the ac- 
celeration of all the metabolic processes. This accelera- 
tion includes the total combustion in calories, the pro- 
tein, carbohydrate, fat and mineral metabolism. In 
states of hypothyroidism the opposite condition of re- 
tardation of metabolic processes occurs. 

Functional tests have therefore been proposed as a 
criterion of the existence of states of hyper- or hy- 
pothyreosis on the basis of increased or diminished oxy- 
gen consumption and protein, carbohydrate, fat and 
mineral metabolism. 

As simpler methods of determining the activity of 
these various processes are developed we may hope that 
this kind of investigation will gradually enter more and 
more into the diagnostic armamentarium of the clinician 
who is interested in measuring the functional integrity 
of the thyroid. But as was said before, the technical 
difficulties which have so far usually surrounded the 
methods of determining and measuring the various 
processes of metabolism have prevented their general 
introduction into clinical medicine. 

The symptoms of Graves' disease which are refer- 
able to concomitant or reciprocal disturbance of func- 
tion of the other endocrinous glands have contributed 
somewhat to the diagnosis of hyperthyreosis from a 
semiological standpoint. This circumstance we shall 
not attempt to develop. But from the standpoint of 
functional diagnosis of the thyreopathies, these disturb- 
ances acquire a considerable importance since they 
open the way, though indirectly, to the development of 
means for testing the functional activity of the thyroid. 
It is quite generally held that the thyroid and the pan- 
creas mutually inhibit one another's activity. The 
pancreas and chromaffin system (adrenals) are likewise 



The Ductless Glands 269 

mutually inhibitory. The thyroid and the adrenals ap- 
pear, however, to reciprocally favor each other's activ- 
ity, that is, an under function of one leads to an under 
function of the other, while an over function of the one 
will lead to an over function of the other. This is the 
teaching of the present Vienna school of endocrinolo- 
gists represented particularly by Eppinger, Hess, 
Falta, Rudinger, and others. According to the teaching 
of this school, a hyperthyroid function will be accom- 
panied by an insufficiency of pancreatic function (inter- 
nal secretion) and by an increased activity of the 
chromaffin or adrenal system. Hypothyroidism, on the 
contrary, will be followed by over function of the inter- 
nal secretion of the pancreas and diminution of adrenal 
functional activity. 

On the basis of these hypotheses, certain tests have 
been devised to disclose a hyper function of the thyroid 
gland. One of these, the so-called adrenalin-mydriasis 
test of Loewi, is used to disclose on the one hand an 
insufficiency of the internal secretion of the pancreas 
and on the other a hyperthyreosis. So far as its ap- 
plication to the investigation of pancreatic insufficiency 
is concerned, the test has already been described (v. s.) 
With reference to the second application, namely that 
of disclosing a hyperthyreosis, details will be later 
given. Tests founded upon the existence of a glyco- 
suria, either spontaneous or following the injection of 
adrenalin, will be considered under the heading Adrenal 
Glands. 

The diagnosis of hyperthyroidism, or Graves' disease, 
is easy in typical cases. The enlarged thyroid, the 
tachycardia, the disturbances of the sympathetic 
nervous system, the tremors, the mental state, the ac- 
celerated metabolism and the blood findings make a 
definite and indubitable diagnostic picture. 



270 Manual of Vital Function Testmg Methods 

There are, however, many cases which elude the clini- 
cian because they are atypical. To these latent or 
atypical cases the French have given the expressive 
title of formes frustes. Barker n has warned us very 
properly that any one of eight different symptoms 
should make the clinician suspicious of Graves' disease. 
The symptoms are: (1) persistent tachycardia (pulse 
above 85); (2) rapid emaciation without apparent 
cause; (3) excessive sweating; (4) persistent watery 
diarrhoea; (5) neurasthenic and psychasthenic states; 
(6) outspoken lymphocytosis; (7) fine tremors of the 
fingers; (8) one or more of the usual ocular symptoms 
of the disease, namely protrusio bulbi or positive Dal- 
rymple, 12 von Graefe, 13 Moebius', 14 Stellwag, 15 Jelli- 
nek 16 and Rosenbach 17 signs. 

Suppose, however, one of these suspicious signs be 
present. How shall it be determined whether or not 
there is actually present a condition of hyperthyroid- 
ism? It is here that a satisfactory functional test would 
be invaluable. Frederich Muller first called attention 
to its necessity under such circumstances. Several 
functional tests are at present available for this pur- 
pose. Unfortunately, they have not been found entirely 
adequate. Nevertheless, they are of a sufficient degree 
of assistance to warrant their retention by the clinician, 
especially as they form an important nucleus upon 
which future investigators may build new theories and 
points of departure for renewed attempts at explora- 
tion. Some of them have not been sufficiently developed 
as yet to allow a final opinion to be formed. 

The tests of hyperfunctional activity of the thyroid 
gland are as follows: 

"Southern Med. Jour., 1914, vii, 1. 

"Widened eye slit; "lagging upper lid; "insufficient converg- 
ence; "infrequent incomplete winking; "pigmented eyelids; 
17 tremor of closed lids. 



The Ductless Glands 271 

1. Hypophysis Test of Claude, Baudouin, and Porak. 

2. The Adrenalin Mydriasis Test of Loewi. 

3. Induction of Experimental or Artificial Hyperthy- 

roidism as a Functional Test. 

4. The Aceto-Nitril Test of Reid Hunt. 

5. Metabolic Studies in the Functional Diagnosis of 

Hyperthyroidism. 

6. The Complement Fixation Reaction as Functional 

Test of Hyperthyroidism. 

7. The Specific Ferment Reaction of Abderhalden, as 

Functional Test of Hyperthyroidism. 

1. The Hypophysis-extract Test for Hyperthyreosis. 
Claude, Baudouin, Porak Test 18 . — Recently Claude, 
Baudouin and Porak have published some interesting 
researches upon the use of extract of the posterior lobe 
of the hypophysis, in disclosing the presence of latent 
hyperthyroidism. 

In their experiments they made use of a hypophyseal 
extract of posterior lobe of such strength that 1 c.c. of 
the substance to be injected was equivalent to ^ of a 
posterior lobe of a beef's hypophysis. This they say 
corresponds to .05 of hypophysis powder. 

This extract was obtained by the action of alcohol 
at 70° upon the hypophysis powder, dried and freed 
from fat. The alcohol is evaporated and the residue re- 
dissolved in normal salt solution. They also employed 
occasionally a watery extract, obtaining results with 
the latter which were practically similar to those ob- 
tained from the former. 

They found that subcutaneous injections of both 
watery and alcoholic extracts of hypophysis produced 
a marked reaction, pallor, glycosuria and diarrhoea, the 

18 Bull, et Mem. Soc. MeU d. Hdp. de Par., 1914, XXX, No. 
22, 1904. 



272 Manual of Vital Function Testing Methods 

greater effects being produced by the watery solution 
and accompanied by greater pain. The alcoholic ex- 
tract was found to be less painful and the pain less 
lasting. 

When a quantity of alcoholic extract corresponding 
to one whole lobe (beef) was injected, the authors noted 
complex effects, such as an action upon smooth muscle 
fiber, a cardiovascular effect and an action on nutrition. 
The diuretic effect was doubtful. 

The action on nutrition was characterized by gly- 
cosuria, the cardiovascular effect consisted of accelera- 
tion of the heart. In these complex effects of the 
hypophysis there appears to be an excitation of the 
sympathetic system shown by the cutaneous vasocon- 
striction and the glycosuria. The accelerator fibers of 
the heart being likewise of sympathetic origin, one would 
naturally expect to find acceleration of the beat. One 
would also expect that with concomitant constriction 
of the peripheral vessels that the blood pressure would 
rise. This phenomenon did not appear. The blood 
pressure remained the same or was lowered. The au- 
thors attribute this to a depressing effect of hypophysis 
extract on the myocardium. They noted occasionally a 
galop rhythm following the injections. With normal 
individuals the authors noted acceleration of the pulse. 

They then proceeded to experiment upon cases of 
Graves' disease. The patients were kept under observa- 
tion free from emotional excitement until the normal 
pulse rate was accurately determined. Injections of 
plain salt solution were tried as controls. 

Thirteen typical Basedowians were used in their ex- 
periments. With the exception of the cardiovascular 
effects the results of injections did not differ from 
those of normal cases. The symptoms, pallor, 
contraction of smooth muscle fiber of intestine 



The Ductless Glands 273 

and uterus, and glycosuria, the latter fairly well 
marked, were noted in the case of Graves' disease. 
Alimentary glycosuria was more readily provoked after 
the injections than before, showing a diminution of the 
already lowered carbohydrate tolerance. The cardio- 
vascular effects of the injections were highly significant. 
In normal subjects the pulse becomes accelerated. The 
acceleration commences two or three minutes after the 
injection. It reaches a maximum in 10 or 15 minutes. 
Then the frequency rapidly diminishes and in about 20 
minutes the pulse is normal. 

In the cases of Graves' disease, however, the results 
were found to be diametrically opposite. The pulse 
which is accelerated before the injection of hypophysis 
extract, becomes quickly slowed. In one of these cases 
the pulse dropped 42 beats. Usually the diminution 
in number of beats is much less, averaging 8 or 10. The 
maximum lowering is reached in about 2 minutes, some- 
times 4 or 6 and rarely even 10. The bradycardia is 
usually ephemeral. Usually in 7 or 8 minutes the 
pulse becomes fast again. Sometimes it was found to 
return to the original number previous to the injection. 
In the majority of instances, however, it remains not- 
ably beneath this point. 

It would appear as a result of these interesting ex- 
periments that extracts of the hypophysis, which nor- 
mally produce tachycardia, bring about an opposite 
effect, namely, bradycardia in case of Graves' disease. 

The authors believe that the extract of hypophysis 
contains principles which simultaneously excite the 
terminations of both sympathetic and vagus fibers. 
This is the only explanation of the complex effects of 
the substance, differing from those of adrenalin, which 
is a pure sympathetic stimulant. Adrenalin, when in- 
jected, causes both glycosuria and tachycardia, but it 



274 Manual of Vital Function Testing Methods 

does not produce, ordinarily, pallor of the skin, nor 
contraction of intestine and uterus, as does hypophysis. 
The pneumogastric is generally considered the nerve 
which produces intestinal peristalsis. Since hypophysis 
produces peristalsis, it must stimulate the 10th pair. 

If now we consider the effects of hypophysis in 
Graves' disease, we may begin by admitting that in this 
condition there is a general state of erethism or hyper- 
excitation of the entire sympathetic and parasympa- 
thetic (vagus-autonomic) systems. That the sympa- 
thetic is excited is proved by the exophthalmus, glyco- 
suria and tachycardia. On the contrary, the symptom 
diarrhoea which is so constant and characteristic a 
symptom in Basedow's disease is explained by Ep- 
pinger and Hess and others on the theory of a hyper- 
vagotonia. 

When one injects into a Basedowian an extract of 
hypophysis, with the exception of the pulse rate, the 
effects are generally similar to those obtained upon the 
normal subject. 

The heart slowing phenomenon, however, found by 
Claude, Baudouin and Porak, in Basedowians following 
injections of hypophysis extract remains to be ac- 
counted for. The authors believe that the slow- 
ing is due simply to stimulation of the vagus 
nerve or 10th pair. They think that hypophysis 
extract acts on the cardiac rhythm of the non- 
Basedowian by stimulating the accelerator sym- 
pathetic. In the Basedowian, however, there is al- 
ready a tachycardia which is due to the continual hyper- 
excitation of the sympathetics. These nerves being 
already in a state of hyperexcitation do not react to 
hypophysis extract. The terminations of the vagus 
which are not excited, therefore, feel the full effect of 
the hypophysis stimulation and the heart is temporarily 



The Ductless Glands 275 

slowed while the effect lasts. 

Naturally, the authors of the "hypophysis test" 
mention the possibility of its use in the diagnosis of 
latent forms of Graves' disease. If future use of this 
test should corroborate the early work of Claude, Bau- 
douin and Porak in this regard the "hypophysis test" 
will become an important adjunct to the functional 
diagnosis of the hyperthyreopathies. 

With respect to its applicability to the diagnosis of 
the forme fruste or latent form of Graves' disease, the 
authors report two very instructive cases. In one a 
woman 27 years of age, of neuropathic taint, suffering 
from tachycardia, dysmenorrhoea and slight hand 
tremor without thyroid enlargement, the injection of 
1 c.c. of hypophysis extract produced a slight increase 
in the rate from 120 to 126 beats. The test was there- 
fore negative. In the second case, that of a nervous 
man 47 years old, with a tachycardia (100 to 105 
pulsations) with slight exophthalmia and slight hand 
tremors, with no apparent thyroid enlargement, the in- 
jection of hypophysis extract slowed the pulse from 
100 to 84 in four minutes. The test was, therefore, 
positive. The case was a true latent form of Graves' 
disease, that is, the syndrome of hyperexcitation of the 
sympathetic nervous system presented by the patient 
was truly connected with and due to a hyperfunctiona- 
tion of the thyroid gland. 

The authors likewise found, which may be mentioned 
for its scientific interest only, that in cases of paroxys- 
mal tachycardia the test is negative, as would on a 
priori grounds be expected. In this condition the 
pathogenesis resides not in the sympathetic nervous sys- 
tem as a whole nor in any dysfunction of the thyroid 
nor any other endocrinopathy but in changes that have 
taken place in the cardiac musculature. 



276 Manual of Vital Function Testing Methods 

£. The A dren alin Mydriasis Test of Loewi 19 .- — In 

1907 Loewi found that in pancreatectomized animals 
the instillation of 1-1000 solution of adrenalin pro- 
duced marked dilation of the pupil. In human beings 
with diabetes Loewi found the same effects. In 30-60 
minutes a marked dilation occurred in diabetic cases. 
The application of this phenomenon to the detection of 
pancreatic insufficiency has already been mentioned. 

Loewi also made a simultaneous observation that the 
instillation of 1-1000 solution of adrenalin into the con- 
junctional sac in cases of Basedow's disease, likewise 
resulted in dilation and proposed the method as a test 
for hyperfunction of the thyroid gland on the ground 
that the internal secretion of the thyroid and suprare- 
nal are synergistic, both acting by stimulating the sym- 
pathetic nervous system. In cases of hyperthyroidism, 
the sympathetic nervous system is in a state of increased 
irritability, therefore the dilator fibers of the iris which 
are governed by sympathetic nerves respond with ab- 
normal alacrity to the instillation of adrenalin. Loewi' s 
findings were corroborated by Falta 20 and Zak. 21 

jEpping er, Falta and Rudinger 22 found an increased 
adrenalin mydriasis in dogs which had been fed with 
thyroid extract. In depancreatized and thyroidectom- 
ized animals the reaction was absent. Eppinger and 
Hess 23 also reported the test positive in Basedow's 
disease. 

The interesting and extremely simple test of Loewi 

19 Wien. klin. Wchnschr., 20, 1907, 782; Archiv f. exper. Path, 
und Pharm., 59, 1908, 83. 

20 Wien. klin. Wchnschr., 20, 1907, 1559. 
21 Verhandl. d. 25 Kong. f. inner. Med., 1908, 392. 

22 Wien. klin. Wchnschr., 21, 1908, 241. 

23 Verhandl. des 26 Kong, f . inner. Med., 1909, 385. 



The Ductless Glands 277 

has not been much discussed in the literature in recent 
years. It would be interesting to determine whether an 
increased susceptibility of the iris sympathetic as 
shown by mydriasis exists in cases of latent Graves' 
disease. 

3. Test of Experimental Hyperthyroidism. Admin- 
istration of Thyroid Extract, iodine and Iodide of Po- 
tassium as a Means of Disclosing Functional Hyper- 
activity of the Thyroid. — Fr. v. Mueller, who criticized 
the metabolism tests for hyperthyroidism as being too 
complex, suggested the administration of iodine as a 
means of disclosing hyperthyreosis. But apparently 
Mueller only made the general suggestion and did not 
elaborate any specified technique. Since no one else 
has done so, it cannot be said that an "iodine test" ex- 
ists for determining the presence of a latent hyperthy- 
roidism. Patients with hyperthyreosis often show in- 
tolerance to iodine by developing emaciation and tachy- 
cardia, after its administration. 

Many attempts to produce experimental thyroidism 
in animals by feeding thyroid substance have been made, 
and there seems to be great variation in the resistance 
of different genera to thyroid ingestion. When symp- 
toms appear in healthy animals the most constant signs 
seem to be emaciation and diarrhoea (Carlson, 24 Bal- 
let 25 ). 

Kraus and Friedenthal 26 found that the intravenous 
injection of thyroid juice in rabbits also produces en- 
largement of the palpebral fissure, projection of eye- 
balls and enlargement of the pupil. Other authors have 
succeeded in obtaining similar results. 

24 Prac. Am. Physiol. Soc, 1910-11, XXVII, p. XIII. 

25 Limousin Med., 1896, XX, 69. 
"Berl. klin. Wchnschr., 1908, 1709. 



278 Manual of Vital Function Testing Methods 

Since the introduction of thyroid preparations into 
clinical medicine, artificially produced hyperthyroidism 
has been observed following their indiscriminate admin- 
istration. The continued injection of thyroid extract 
is frequently followed by symptoms of intolerance such 
as subjective sensations of heat, perspiration, palpita- 
tion or tachycardia and occasionally glycosuria, all of 
which denote hyperthyroidism. 

A few cases have been reported in which a typical 
Graves' disease syndrome has been produced by the 
administration of thyroid extract. The symptoms dis- 
appeared after a suspension of the treatment. 

It is a well known fact that the administration of 
iodides over long periods to cases of goitre may pro- 
duce symptoms of hyperthyroidism (Kocher). 27 To 
these cases the name iodine-Basedow has been given. 

The actual administration of thyroid extract, iodine, 
and iodide of potassium to disclose a latent hyperthy- 
roidism or Graves' disease is not to be recommended as 
a routine procedure. Most writers advise against the 
use of iodine, iodides or thyroid extract in any case 
where there are signs of emaciation (Krecke 28 ). 

Taking all the above facts into consideration, it will 
no doubt be admitted that there is little, if any, justi- 
fication for the administration of either iodides, iodine 
or thyroid extract in cases of suspected Graves' syn- 
drome with a view of thereby developing indubitable 
signs of the disease. It cannot be said to be justifiable 
under any circumstances to attempt to convert a latent 
or doubtful into an outspoken case of Graves' disease 
for purposes of diagnosis. 

There appears to be among many medical men a 

"Verhandl. d. Deutsch. Ges. f. Chir., BerL, 1910, 396. 
28 Munch, med. Wchnschr., 1911, LVIII, 1601 and 1676. 



The Ductless Glands 279 

lack of appreciation of the dangers which are attached 
to the indiscriminate use of thyroid extract and some 
surgeons have stated that many cases of Graves' dis- 
ease coming under their observation for operation give 
a history of previous ingestion of thyroid extract. 
It would certainly seem rational to assume that noth- 
ing but harm can come from such a practice. 

These facts are, of course, well known and appreci- 
ated by a very large majority of medical men, and be- 
cause of this knowledge no systematic attempt has 
ever been made to develop a test of experimental thy- 
roidism. The use of thyroid extract, iodides, or iodine 
for such a purpose can only be mentioned to be con- 
demned. 

b. The Aceto-Nitril Test of Reid Hunt. — It was 
in the effort to develop a quick and satisfactory method 
for comparing the physiological activity of different 
thyroid preparations that Hunt 29 discovered the re- 
markable fact that mice when fed upon thyroids de- 
velop an increased resistance to aceto-nitril or methyl 
cyanide, CH.CN. This substance produces toxic ef- 
fects chiefly through the slow liberation of hydrocyanic 
acid in the body. Since thyroid feeding does not alter 
the resistance of mice to hydrocyanic acid, it is proba- 
ble that its action, so far as aceto-nitril is concerned, 
is exerted upon the processes by which the substance is 
decomposed in the organism. 

Hunt found that when small amounts of thyroid 
are fed to mice for a few days these animals acquire 
a markedly increased resistance to aceto-nitril. This 

"Amer. Jour, of Physiol., 1899, III; Proc. Soc. Exp. Biol., N. 
Y., 1905, Oct. 18; Jour. Biol. Chem., I, 33, Oct., 1905; Jour. Amer. 
Med. Assn., 1906, XL VII, 790; Hygien. Lab. Bull., No. 47, 1907. 



280 Manual of Vital Function Testing Methods 

is true for both white and gray mice, although most of 
his experiments were performed upon the former va- 
riety. 

A mouse which had received thyroid in the form 
of cakes, recovered from 17 times the relative amount 
of aceto-nitril fatal to a control. Another mouse 
recovered from 16 times the relative dose fatal to con- 
trols. A third mouse recovered from 11 times, a fourth 
from 6 times and a fifth from 2^ times the fatal dose 
to controls. 

Hunt suggested this reaction as a delicate test for 
thyroid substance. 30 He found no other substance with 
an effect upon the resistance of mice to aceto-nitril at 
all comparable to thyroid. The test is more delicate 
than any chemical test. 

Hunt suggested in 1907 that this method is adapted 
to throw light on the question as to whether there is 
an excessive amount of thyroid secretion in the blood 
in cases of Graves' disease. He applied the test in three 
cases. In one of these the blood of the patient had a 
marked effect in increasing the resistance of mice to 
aceto-nitril, indicating thereby an excess of thyroid 
secretion. In a second case the results were doubtful 
and in a third case, negative. 

Hunt suggested that the test might have some diag- 
nostic value though he points out that it is not neces- 
sary to assume that in Graves' disease there is always 
an excess of thyroid secretion present in the blood at 
all times. 

To carry out the method, he suggested that the 
best results might be obtained by administering to 
mice 1 or 2 c.c. of blood made up with meal in the 
form of cakes, for 9 or 10 days before testing with 

80 Jour. Amer. Med. Assn., 1907, XLIX, 240. 



The Ductless Glands 281 

nitril. Controls are indispensable. One-fourth of a 
milligram of aceto-nitril per gram of body weight of 
mouse may be fatal to a normal animal in a few hours. 
Hunt used doses of a fraction of a milligram, one- 
fourth, to several milligrams, 1, 2, 4, in his experi- 
ments. 

Hunt believed as a result of his researches that the 
activity of a given thyroid preparation or substance 
is parallel with its iodine content. 

The test suggested by Reid Hunt has not been 
extensively developed. His findings were, however, sub- 
stantially corroborated by several authors, among 
whom may be mentioned Trendelenburg in 1910, 31 
Ghedeni in 1911. 32 

Before a final judgment as to the value of this pro- 
cedure can be formed it will be necessary to determine 
the resistance of mice to aceto-nitril after feeding with 
the blood of patients with Graves' disease in a large 
series of cases. Also experiments should be done to 
determine the resistance of mice to aceto-nitril after 
feeding with normal blood, for perhaps the test is so 
delicate that even the amounts of thyroid secretions 
present under normal circumstances may be sufficient 
to increase the animal's resistance. Of course the vari- 
ations in natural resistance of the animals both as 
regards species and seasons which have already been 
demonstrated as well as the possible variations in the 
blood content of thyroid substance even under normal 
circumstances may so complicate and obscure results 
that the test may be found impracticable. 

There is, however, something extremely suggestive 
about this type of biological experimentation which 
makes it seem probable that some such test will be 

81 Biochemische Zeitschr., 1910. 

82 Wien. klin. Wchnschr., 1911, XXIV, 736. 



282 Manual of Vital Function Testing Methods 

discovered in the future of real value in the diagnosis 
of hyperthyreosis. 



5. Metabolic Studies as Criteria* of Hyperthyroidism. 
— In Graves' disease, as was above mentioned, the 
metabolic changes are increased. Biedl says they are 
so characteristic of the condition as to constitute an 
important diagnostic criterion. The metabolism of 
Graves' disease is accompanied by a pretty constant 
increase in the expenditure of energy. 

The respiratory gas interchange shows an increase 
of 50%, sometimes 70% to 80% in the amount of oxy- 
gen consumed, according to Magnus-Levy, 33 Salomon, 34 
and others. 

The increased production of heat is usually accom- 
panied by an augmented metabolism of albumen and 
fats. The assimilation of carbohydrates is diminished 
in Graves' disease and it is for this reason that ali- 
mentary glycosuria is readily produced. 

Kraus was the first to suggest that determinations 
of the respiratory metabolism (increase of C0 2 and N), 
by the use of the Zuntz-Geppert apparatus may be use- 
ful in the functional diagnosis of latent or outspoken 
hyperthyroidism. Fr. v. Mueller, however, observed 
that the method is too complicated for practical work. 

Studies of basal metabolism can be calculated by 
indirect calorimetry from the oxygen absorption and 
the respiratory quotient, using a Benedict unit appar- 
atus (mouthpiece and spirometer). At least three 
ten-minute periods are run and the average taken for 
that day's basal metabolism. 

^Berl. klin. Wchnschr., 1895; Zeit. f. klin. Med., 33, 1897; Noor- 
dem's Handbook d. Path. Stoffwechs., II, 352, 1907. 
84 Berl. klin. Wchnschr., 1904. 



The Ductless Glands 283 

Means 35 has recently reported some studies of basal 
metabolism and its relation to body surface in obesity, 
myxedema and pituitary disease. He found a diminu- 
tion of 27% below normal in myxedema. 

The emaciation which occurs in many cases of Graves' 
disease naturally points to an increased katabolism. 
Kocher found reduction in weight in 88% of his cases. 
As much as 15 to 20 kgs. may be lost in a few 
months. The loss of weight is an early symptom. The 
basic cause for this loss in weight is the remarkable 
increase in the caloric production which occurs in 
Graves' disease. By using the Zuntz-Geppert appa- 
ratus many authors have made the demonstration of 
increased oxygen consumption and increased C0 2 elim- 
ination. Magnus-Levy and Salomon have already been 
mentioned. 

Experiments have also been made in the Voit-Petten- 
kofer apparatus which give like results. The increase 
of caloric production as was before stated may reach 
as high as 70% or more above normal. In some cases 
(Magnus-Levy) the oxygen consumption has been found 
from over 5 to nearly 7 ccm. per kilogram of body 
weight. Salomon has shown that these metabolic dis- 
turbances occur and may be demonstrated in the latent 
cases. 

It is to be hoped that the gradual simplification of 
methods for studying metabolism will lead to practical 
clinical results which will undoubtedly find a rich field 
of application in the functional diagnosis of thyroid 
diseases. 

6. Application of the Principle of Complement Devia- 
tion to Functional Diagnosis of Hyperthyroidism. 
Troc. Soc. fr. Exp. Biol, and Med., 1914, XII, 1913. 



284< Manual of Vital Function Testing Methods 

Marinesco-Roseo Test. — Marinesco 36 in 1911 and 
Roseo 37 in 1912 appear to have been the first to sug- 
gest that in Graves' disease there is thrown out into 
the blood serum sufficient thyroid substance (antigen) 
to give rise to the formation of antibodies (ambocep- 
tors) in the patient's blood. They therefore proposed 
to test for the presence of these antibodies in the blood 
serum of suspected cases of Graves' disease by means 
of an antigen prepared from thyroid tissue removed 
at operation from an outspoken case of Graves' disease. 

Both Marinesco and Roseo have studied the reaction 
of fixation of alexine (complement) in cases of Base- 
dow disease and they believe that the positive results 
obtained proved the existence of true specific antibodies 
in the blood in this condition. This test may in future 
be found useful from the standpoint of functional diag- 
nosis. 

The principle of the complement fixation or deviation 
test depends, as is well known, upon the observation 
that the injection of the living organism with bodies of 
a proteid nature, cells, bacteria, organ extracts, etc., 
results in the formation by the organism of certain an- 
tagonistic bodies called antibodies. Perhaps these anti- 
bodies are ferments. The bodies that are inoculated 
in order to produce antibodies are called antigens. 
Some antibodies such as the agglutinins and precipitins 
act directly on the specific agent or antigen which 
produces them. Other antibodies, such as cytolysins 
and hemolysins, act only in the presence of a third 
body, which is always present in blood serum or tissue 
juices to which the name complement has been given. 
It is upon this state of facts that the now famous Was- 

M Deutsch. Zeits. f. Nervenheilk., 1911, XLI, 26$. 
"Biochem e terap. sper., Milan, 1912-13, IV, 1. 



The Ductless Glands 285 

sermann reaction is founded. The performance of the 
complement fixation test particularly in the diagnosis of 
syphilis has become a part of the routine work of almost 
every well equipped pathological clinical laboratory. 
Consequently there will be no difficulty in a well 
equipped hospital for the clinician to have complement 
fixation tests performed. 

I have been unable to obtain the exact results of 
Roseo's work. Marinesco's 38 observations upon the 
reaction of fixation of complement included two series 
of experiments. In the first he used an aqueous extract 
of goitre from a classical case of Graves' disease as 
antigen and the serum of the same patient for antibodies 
and that of four other patients with the same disease. 
For controls he used the serum of normal persons. The 
fixation was complete in the first case whose goitre 
furnished the antigen, while in two other Basedowians 
there was incomplete hemolysis, and in a fourth the 
hemolysis was complete as in a normal control. An 
objection which may be urged against this first series as 
pointed out by Marinesco is that he did not have at 
his disposition an extract of normal thyroid. Later, 
with the assistance of Madame Papazol, he repeated 
his experiments, this time making an examination of 
23 sera, and using different extracts from the thyroid 
gland of cases of Graves 5 disease, also from one goitrous 
thyroid and one normal gland. 

The extracts were prepared in the usual way for 
ether extracts. Eight grams of Basedow goitre were 
triturated in a mortar and 100 grams of ether added, 
drop by drop. The mixture was put in a sterilized 
glass and placed in a shaker. After shaking and filtra- 
tion, the mixture was kept for 48 hours in the thermo- 

88 Loco citato. 



286 Manual of Vital Function Testing Methods 

stat. After the evaporation of the ether a little car- 
bolated water was added, 40 c.c. for 8 grams of sub- 
stance. The extract was then again shaken and filtered 
through cloth. The prepared extract was kept on ice 
in a dark bottle. The alcoholic extract was similarly 
prepared. 

In the two cases in which Marinesco made use of an 
autoextract of the thyroid from cases of Graves' dis- 
ease, the prevention of hemolysis was complete. He 
found the same absolute prevention of hemolysis in six 
other cases of Graves' disease when he employed thyroid 
tissues obtained from other Basedowians. Aqueous, al- 
coholic and ethereal extracts appeared to act about the 
same, but sometimes the ether extract seemed more 
active. 

In most cases of Graves' disease Marinesco obtained 
either a total absence of hemolysis or an incomplete or 
partial one. On the contrary, the serum of Graves' 
disease cases never fixed complement in the presence of 
normal thyroid body or extract of ordinary goitre. 
He got the same results when he used serum from normal 
persons and Basedowian antigen. In one case, however, 
Marinesco and Madame Papazol found that the serum 
of a syphilitic patient gave a partial hemolysis with 
ether and alcoholic extract of normal thyroid. Other 
authors have likewise found a more or less complete 
fixation with syphilitic serum in the presence of normal 
thyroid extract. Mueller, of Vienna, in a personal com- 
munication to Marinesco stated that in a case of 
Graves' disease he had noted a fixation of complement 
in the presence of alcoholic extract of heart. 

Marinesco believes that his experiments tend to show 
the presence of an antigen in the thyroid gland of Base- 
dowians and that the reactions of fixation which he 



The Ductless Glands 287 

obtained are not simply due to an increase in the active 
substance (internal secretion) of the thyroid gland but 
to a change in the colloidal state of this substance, due 
to the harmful effects of a pathogenic agent. Marines- 
co calls attention to the difficulty in penetrating more 
deeply into the mechanism of his fixation reaction since 
authors in general are by no means in accord in explain- 
ing the mechanism of the fixation reaction discovered 
by Wassermann in the serum of syphilis. Some authors 
like Wassermann himself, seeing in the reaction the 
existence of true specific syphilitic antibodies, others on 
the contrary considering it as a non-specific physical 
chemical phenomenon. 

The practical possibilities for functional diagnosis 
of his findings are believed by Marinesco to be worthy 
of mention. 

For the Marinesco-Roseo test it will of course be 
necessary to secure thyroid gland tissue at the time of 
operation in a case of outspoken Graves' disease. 

As to the clinical value of the test so little work has 
been done by investigators subsequent to the reports 
of Marinesco and Roseo that no definite opinion can 
be formed as to its value. This will become a matter 
for future investigation. It is to be hoped that the test 
will be carried out in a sufficient number of outspoken 
cases of Basedow's disease to determine in just what 
percentage it will be positive. If the findings are cor- 
roborated, the test should be applied to a series of cases 
of suspected latent hyperthyroidism. At the present 
time the final decision as to its value remains sub judice. 

7. Specific Ferment Test of Abderhalden Applied to 
Functional Diagnosis of the Thyroid. — Lampe 39 has 
» Munch, med. Wchnschr., 1913, 26. 



288 Manual of Vital Function Testing Methods 

attempted to apply the Abderhalden dialysis method 
to the study of the blood serum of patients with Graves' 
disease. He believes that in the blood serum of these 
patients ferments exist which are specific for thyroid 
tissue. 

This method has never been applied extensively to 
the functional diagnosis of incipient Graves' disease 
since its introduction by Lampe. The technical diffi- 
culties attached to the carrying out of Abderhalden's 
method and the many conflicting results obtained in 
its general use have prevented it from becoming popu- 
lar in clinical practice. Perhaps in the future when the 
method is simplified and its precise limitations defined, 
some practical results may be hoped for. 

Lampe first demonstrated in 1913 that normal blood 
serum obtained from healthy individuals does not con- 
tain any ferments capable of splitting the tissues of any 
of the organs. 

In the same year Lampe and Papazolu 40 examined 
the effects of the serum from cases of Graves' disease 
to determine the presence or absence of proteolytic fer- 
ments specific for thyroid tissue. Lampe thought that 
by the results of the dialysis method he might be enabled 
to throw some light upon the question as to whether in 
Basedow's disease there is a hyperthyroidism or a dys- 
thyroidism. He does not mention the possibility of 
employing the test as an aid towards the functional 
diagnosis of the disease. 

Lampe argued that if in Graves' disease there is an 
over-production of the normal thyroid secretion, there- 
fore a negative result of the Abderhalden reaction 
(serum -f- thyroid gland) would be expected because 
in this case there would simply be the introduction into 
the blood of a purely native protein only in increased 

40 Munch, med. Wchnschr., 1913, 28. 



The Ductless Glands 289 

amounts and consequently no development of ferments. 
If on the contrary, Graves' disease is a true dysthyroid- 
ism, if, in other words, the thyroid gland in Graves' 
disease pours into the blood a qualitatively altered pro- 
teid secretion, produced by the pathological changes 
in the gland, then this secretion acting as a foreign 
proteid would be expected to stimulate the produc- 
tion of protective ferments, and the Abderhalden reac- 
tion would be positive. Lampe hoped also to be able to 
throw some light by his method upon the role which the 
thymus plays in Graves' disease. 

Lampe and Papazolu experimented with the serum 
from Basedow cases upon normal thyroid gland, ex- 
ophthalmic goitre gland, cystic and parenchymatous 
goitre, normal thymus, Basedow thymus and several 
other organs and tissues as ovary, testicle, kidney, su- 
prarenal, pancreas, etc. In their article they give the 
protocols of experiments upon the serum of twenty-five 
cases of exophthalmic goitre. 

In all cases in which the serum from the Graves' 
disease cases was allowed to act upon exophthalmic goi- 
tre tissue, the tissue was digested. In very few cases 
only was the reaction positive when normal thyroid 
tissue was used. In four out of five of the cystic goitre 
products, in almost all thymus and ovarian tissues they 
found the reaction positive. With all other substrata, 
kidney, liver, pancreas, etc., the reaction was negative. 

Lampe believes that his researches demonstrate that 
in Graves' disease there is a true dysthyroidism and 
not a simple hyperthyroidism. 

Principle of the Abderhalden Method. — The basic 
principle underlying the now much discussed method 
of Abderhalden 41 is the fact that albumen, being a 

41 Defensive Ferments of Animal Organism, Abderhalden; tr. 
by Gavronsky and Lanchester, Lond. Bale. Co., 1914. 



290 Manual of Vital Function Testing Methods 

colloid does not diffuse through animal membranes, 
while, on the other hand, the peptones, which are the 
first products of its decomposition, are diffusible. If 
albumen is put in a dialysing tube and the latter placed 
in water no albumen appears in the surrounding fluid, 
even after a considerable lapse of time. If pepsin and 
HC1 are added to the albumen solution peptones are 
formed and will appear in the dialysate. If it is desired 
to determine whether a liquid contains any proteolytic 
substance or ferments, the solution may be placed in a 
dialysing tube and peptone will appear in the surround- 
ing media. 

In this way blood serum, cerebrospinal fluid, lymph, 
extracts of organs, etc., may be tested. 

The actual carrying out of the Abderhalden method 
is extremely difficult, so much so that the method can- 
not be used in the ordinary routine of clinical work. If 
the method is to be tried the individual who proposes 
to do so will find it advantageous to consult the little 
work of Abderhalden himself, which has recently been 
translated and to which reference has been given. 

8. Hypo] 'unction of the Thyroid Gland (Myxedema- 
tous States) 

The best concrete example of the loss of function of 
the thyroid in human beings is met with in those cases 
in which the whole gland has been removed by opera- 
tion for goitre. 

Reverdin 42 in 1882 was the first to describe the 
results of goitre extirpation. In 1882 Kocher 43 pub- 
lished his classical report on the same condition. The 

43 Rev. Med de le Suisse Rom., 1889, 539. 
"Archiv f. klin. Chir., 1883, XXIX. 



The Ductless Glands 291 

names operative myxedema or cachexia strumipriva 
were given to this condition. Inasmuch as the thyroid 
gland is never completely excised at the present day the 
subject has become of historical interest only. 

What is of greater practical moment is the fact 
that symptoms somewhat similar to the cachexia 
strumipriva may spontaneously arise in adult human 
beings and give rise to the now well known but only 
too often overlooked syndrome of spontaneous or 
idiopathic myxedema of adults, Gull's disease. The 
symptoms are produced by retrogressive changes in the 
thyroid gland. Similarly there may be congenital 
states of hypothyroidism and infantile types, develop- 
ing after birth, the so-called sporadic cretinism. Fi- 
nally in some countries a condition known as endemic 
cretinism exists. All the above types of disease are 
associated with a diminution of function of the thyroid 
gland. 

In all states of hypothyroidism the gland itself under- 
goes retrogressive changes. There are symptoms refer- 
able to the skin and subcutaneous tissues, the nervous 
system, metabolism, the bones, blood, etc. We shall not 
attempt to go into details in regard to the semiology 
of these interesting conditions. 

The diagnosis of myxedematous states is easy in 
typical cases but even here many cases are overlooked 
by the practitioner. In latent cases, however, the 
-formes frustes, the diagnosis may not be easy. Some- 
times the edema is taken to mean B right's disease. I 
have seen the nervous symptoms, speech difficulties and 
gait disturbance ascribed to chronic alcoholism. 44 
Kocher calls the latent form of myxedema, thyropenia. 
All authors call attention to the great frequency with 
which it is overlooked. 

"Jour. Am. Med. Assn., 1915, LXIV, 986. 



292 Manual of Vital Function Testing Methods 

The functional diagnosis of thyropenia is intimately 
bound up with the treatment for there is but one diffi- 
culty and that is to suspect the disease. Once sus- 
pected there is one infallible test, the therapeutic 
test. 

Therapeutic Test for Lowered Functional Activity 
of the Thyroid Gland. — This consists in commencing 
the administration of thyroid extract. If the case is 
one of thyroid insufficiency the symptoms will magically 
disappear. If they are not entirely gone or improved 
in two weeks, the test is negative. The condition is not 
one of hypothyroidism. 

Thyroid gland is best given in the form of tablets 
of the dried gland. The tablets contain 1% to 5 grains 
(.1— .3 gm.) of desiccated thyroid gland. Begin by 
administering a small dose after each meal or less often. 
The patient should lie down for twenty minutes after 
swallowing the tablet. 

The dose is gradually increased until 6-10 tablets 
per day are given, care being taken not to produce rapid 
heart action, sweating, diarrhoea or nervousness, which 
are symptoms of intolerance. 

From a therapeutic standpoint, which point we can- 
not discuss in this place, it is well known that the ad- 
ministration of thyroid gland in states of hypothyroid- 
ism must be kept up indefinitely, for so soon as the 
treatment is stopped, the symptoms will invariably 
recur. 

II. THE PARATHYROID GLANDS 

The first person to specifically describe the para- 
thyroids was the Swedish anatomist, Sandstrom, in 
1880. Gley practically rediscovered them in 1891. 



The Ductless Glands 293 

Since the latter date a very considerable literature has 
risen upon these interesting structures. 

Following the removal of two or more of the four 
parathyroid glands in the human subject, tetany comes 
on in from 2 to 5 days. All the special symptoms of 
tetany are present. Trousseau's, Erb's, Chvostek's and 
Hoffmann's signs, with irritability of the nerves of spe- 
cial sense and the sympathetic, irregular pulse, arterial 
spasm, angioneurotic edema, spasm of gastrointestinal 
tract, leucocytosis and disturbance of heat regulation 
may occur. 

After incomplete extirpation or temporary injury 
of the glands, milder symptoms occur called tetanoid or 
subtetanic hypoparathyreosis (Halsted). Sometimes 
the symptoms are latent and come on sometime after 
injury or as a result of pregnancy, trauma or infection. 
In the well-known infantile tetany lesions of the para- 
thyroids have been found. 

Other convulsive diseases such as epilepsy, paralysis 
agitans, myoclonus, myotonia and myasthenia have 
been supposed to be due to disease of the parathyroids, 
but the exact facts in this direction are as yet unknown. 

The exact relation between the thyroids and para- 
thyroids is not known, some thinking that an an- 
tagonism, others that a synergism, exists between the 
two. 

There is no method at present known of experimen- 
tally determining the functional activity of the para- 
thyroid glands. 

in. THE THYMUS GLAND 

The function of the thymus is as yet not definitely 
known. It is assumed that inasmuch as the basic 



294 Manual of Vital Function Testmg Methods 

structure of the thymus is that of lymphoid tissue in 
general, that there is a related function between the 
two, in other words, that lymphocytes and eosinophiles 
are formed in the gland. 

There are, however, present in the thymus structure 
some epithelial elments, the so-called corpuscles of 
Hassal. What their function may be is quite unknown. 
Many believe that in the epithelial cells an internal se- 
cretion is elaborated which has to do with the develop- 
ment of the skeleton, nervous system, sexual apparatus 
and general metabolism. 

There is a general belief that a reciprocal action 
exists between the thymus and testes, since castration 
delays the involution of the thymus while removal of 
the thymus causes rapid development of the testes. 

The fullest development of the thymus is reached 
at the end of the second year of life. From this time 
on to puberty it gradually atrophies and in adults is 
represented only by a small mass of fibrous tissue and 
fat. Occasionally, however, the thymus gland persists 
or undergoes hypertrophy, producing symptoms of 
tracheal stenosis with attacks of laryngeal stridor or 
asthma, and sometimes there is sudden death, the so- 
called mors thymic a. A condition known as the status 
lymphaticus may gradually develop in which there is 
more or less anemia, with lymphocytosis, together with 
rachitic and gastrointestinal symptoms. 

No tests have so far been devised for determining the 
functional activity of the thymus. The diagnosis of 
its diseases is strictly semiological and in the diagnosis, 
radiography has recently been of considerable assist- 
ance. 






The Ductless Glands 295 

IV. THE SUPRARENAL GLANDS 

Our more intimate knowledge of the suprarenal 
glands appears to date from the year 1855, when Addi- 
son published his famous work upon the disease which 
bears his name, though they have been known since 
1564, the date of their discovery by Eustachius. 

A tremendous amount of work has been done upon 
the adrenals by investigators in the past half century. 
Much remains to be learned but certain facts appear to 
have been gained. These may be briefly stated as fol- 
lows : disease of the glands resulting in their gradual 
atrophy or destruction gives rise to a train of symp- 
toms characterized chiefly by pigmentation of the skin 
and extreme weakness, i. e., Addison's disease. Ex- 
tirpation in animals of both adrenals is an extremely 
dangerous operation and according to most authori- 
ties leads infallibly to death. Extracts obtained from 
the medullary or central part of the organ are toxic 
when administered to animals, among the symptoms 
being glycosuria and arterial degenerations. The 
same extracts when injected intravenously produce a 
powerful constriction of the blood vessels with rise of 
the blood pressure due to stimulation of the sympa- 
thetic nervous system. 

It is generally accepted by clinicians and patholo- 
gists that the adrenal medulla elaborates an internal 
secretion and that adrenin is the product of this se- 
cretion. 

The exact function of the adrenal cortex is still un- 
known. The cortex contains a considerable quantity 
of lipoid and cholinogen substances, the presence of 
which has given rise to the hypothesis that neutraliza- 
tion of toxic substances is effected here. 

In 1894 Oliver and Schafer noted that extracts of 
adrenal medulla produce a rise of blood pressure. In 



296 Manual of Vital Function Testing Methods 

1897 and 1898 Furth and Abel and in 1901 Takamine 
and Aldrich succeeded in gradually separating and 
finally isolating in pure form the active substance of 
adrenal medulla — adrenin. 

From a clinical standpoint the functional activity of 
the suprarenal glands may be considered from two 
points of view. From the first the functional activity 
of the glands may be considered to be lowered and 
from the second it may be regarded as raised. To 
the first condition, the name hypoepinephria or hypo- 
adrenalism has been given, and to the second hyper- 
epinephria or hyperadrenalism. 

In our brief discussion of the functional examination 
of the suprarenal glands this classification will be found 
most practical. 

We may properly allude here again to the antago- 
nism which is generally considered to exist between the 
function of the adrenals (chromaffin system) and the 
pancreas. It has already been stated that the adrenals 
and thyroid are functional synergists. The adrenal 
secretion inhibits carbohydrate catabolism and raises 
blood sugar, while the pancreas hormone facilitates 
carbohydrate catabolism and lowers blood sugar. The 
effect then of lowering the adrenal function is to raise 
that of the pancreas, namely, to facilitate carbohydrate 
catabolism and lower blood sugar to lead to hypogly- 
cemia, oliguria and hence absence of glycosuria. The 
effect of raising the adrenal function will be to inhibit 
carbohydrate catabolism and to raise blood sugar, 
hence to lead to hyperglycemia, diuresis and glycosuria. 

1. Hypo function of the Suprarenal Glands 

Several different clinical forms of hypoepinephria or 
lowered adrenal function have been described, but few 



The Ductless Glands 297 

of them have been generally recognized by clinicians as 
separate morbid entities. The essential features of 
lowered adrenal function appear to be myasthenia and 
hypotension. The systolic blood pressure is usually 
below 100 mm. Other features justifying a suspicion 
of hypoepinephria are hyperesthesias, lumbar pains, 
headache, delirium, coma, digestive disturbances and 
sudden death without previous symptoms. 

The chief clinical entity which is recognized as be- 
ing accompanied by a true persistent hypoadrenalism 
is Addison's disease. 

Addison's disease, first described by Thomas Addison 
in 1855, is a chronic condition usually appearing in the 
third or fourth decade of life. It is characterized 
clinically by pigmentation of the skin and mucous 
membranes, by muscular and vascular weakness, dis- 
turbances of the gastrointestinal tract and nervous 
system, and final cachexia and death. Anatomically 
it is accompanied by disease of both adrenals, usually 
a caseous tuberculosis. We shall not attempt a de- 
scription of the symptomatology or pathology of the 
disease. 

The clinical diagnosis of outspoken cases of Addi- 
son's disease is sometimes easy. If there is a definite 
history of weakness, vomiting, constipation and 
diarrhoea, abdominal and lumbar pains and there is 
present a pigmentation of the skin and mucous mem- 
branes, and when pernicious ansemia and a few other 
conditions which might be confused with it can be ex- 
cluded, the diagnosis is reasonably certain. In Addi- 
son's disease there is a mononucleosis and a hyper- 
eosinophilia, in the blood. 

Before the pigmentation occurs, however, the diag- 
nosis is extremely difficult or impossible. Latent Ad- 
dison's disease and other conditions of hypoepinephria 



298 Manual of Vital Function Testing Methods 

can only be disclosed by the application of principles 
of functional diagnostic methods. Unfortunately, the 
principles upon which a functional investigation might 
be applied, toward the elucidation of adrenal dis- 
turbances, have not been as yet developed to an extent 
where they can be of great practical assistance to the 
clinician. 

One very evident possibility, however, suggests it- 
self. If states of hypoepinephria are accompanied 
by diminished function of the adrenals, there must be 
a lessened amount of the substances in the blood which 
represent the gland's activity. There is no practical 
way at present to make use of such an hypothesis. 
Tests for increased amounts of adrenalin in the blood 
have been used to discover the opposite state of hyper- 
adrenalism and these tests will be described below. 

Eppinger, Falta and Rudinger 45 showed that in 
cases of Addison's disease (hypoadrenalism) the 
sugar tolerance is remarkably high. Polak 46 was un- 
able to produce a glycosuria with 2 mg. doses of 
adrenalin in a case of Addison's disease. Similar doses 
in normal persons invariably produce glycosuria. 
Meyer and Kahn corroborated these findings. These 
facts form the basis for the application of various kinds 
of glycosuria tests to the functional diagnosis of 
hypoadrenalism. 

Tests of Increased Sugar Tolerance as Evidence of 

Hypoadrenal Function. — The so-called sugar tests 

have been described at length in the chapter on liver 

function testing. (See page 17.) In every case of 

suspected adrenal disease the sugar tolerance should be 

investigated. 

46 See Erkrankungen der Blutdrusen. Falta. Wien, 1913. 
"Wien. klin. Wchnschr., 1909. 



The Ductless Glands 299 



#. Hyperf unction of the Suprarenal Glands 

Just what morbid conditions are associated with or 
produced by hyperfunction of the adrenals is by no 
means clearly understood. Certain tumors of the chro- 
maffin tissues have been held to produce symptoms con- 
nected in some way with hyperadrenalism. The ques- 
tion as to whether other conditions besides tumors of 
the adrenals can give rise to states of hyperfunction is 
not decided. 

A number of pathological states of the organism 
have at one time or another been claimed to owe their 
origin to hyperfunction of the suprarenal glands or 
chromaffin tissues generally. A school of pathologists 
in France has for a long time endeavored to explain the 
heightened blood pressure of nephritis on the ground 
of an increased function of the suprarenal glands. 
Further than this it has been held that the arterio- 
sclerosis which accompanies the circulatory hypertonia 
is the result of hyper adrenal function. Finally accord- 
ing to some pathologists the whole process, of which 
circulatory hypertonia and nephritis form important 
parts, is to be ascribed to a primary hyperplasia of 
the chromaffin tissues. 

Certain authors have contended that they were able 
in such conditions to demonstrate by means of the 
Ehrmann-Meltzer reaction (v.i.) the presence of ex- 
cessive amounts of adrenalin in the blood. 

The question as to just what pathological processes 
and clinical syndromes are to be held related to hyper- 
adrenalism as effect to cause, is a question almost 
entirely open and undecided at the present time. Fur- 
ther than this the subject of functional diagnosis of 



SOO Manual of Vital Function Testing Methods 

hyperactive states of the adrenal glands has only begun 
to be developed. 

The principal methods suggested are two in number. 
The first depends upon the generally accepted influence 
of hyperadrenalism upon the carbohydrate metabolism. 
There is said to be always a hyperglycemia. Hence 
the demonstration of an excess of sugar in the blood 
is one method of diagnosing a hyperepinephria, pro- 
vided, of course, that other causes of hyperglycemia can 
be excluded. There is unfortunately no simple method 
of making the test. 

The second class of functional tests for hyperad- 
renalism depends upon the demonstration of excess 
of adrenalin in the blood and the production of gly- 
cosuria following the injection of adrenalin. 

S. Tests for Adrenalin in the Blood as an Evidence of 
Hyperadrenalism. The Ehrmann-Melt zer Reaction 

It has long been known that intravenous injection of 
adrenalin produces dilatation of the pupil. This fact 
has been utilized as a test for adrenalin in various 
fluids, as blood serum, urine, etc. 

Meltzer and Auer, 47 Wessely 48 and others have 
found that when adrenalin is applied to the frog's eye 
mydriasis is produced. 

Ehrmann 49 studied this phenomenon and suggested 
it as a delicate test for adrenalin. He found that 
adrenalin acts upon the dilator (sympathetic) fibers 
of the iris in a strength of 1 to 20,000,000. Dilatation 
of the pupil of the frog's bulbus oculi immersed in salt 
solution occurs when excessively minute quantities of 

"Centralbl. f. Physiol., 1904, XVIII, 316. 

48 Zeitsch. f. Augenh., Aug. 13, 1905. 

49 Archiv f . exper. Path. u. Pharm., 1905, LIII, 96. 



The Ductless Glands 301 

adrenalin are present, quantities as small as .000025 
mg. Later investigations have shown, however, that 
other substances in blood serum will produce the same 
reaction and therefore the practical availability of the 
reaction as a test for adrenalin in the serum is vitiated. 



4. Adrenalin Glycosuria as a Test of Hyperf unction of 
the Chromaffin System 

We owe to Blum 50 the discovery that the hypodermic 
injection of adrenalin will occasionally produce 
glycosuria. The reducing substance found in the urine 
has been proved to be glucose and there is always a 
hyperglycemia (Metzger 51 ). The action of adrenalin 
in thus producing a hyperglycemia is due to its well 
known stimulating effect upon the sympathetic nervous 
system (Underhill 52 ) acting upon sugar storing organs 
and causing them to relinquish their supply of dextrose 
producing substances as glycogen. 

Soon after Blum made this discovery the interesting 
fact was tested and confirmed in many directions. It 
was discovered that the glycosuria appears after the 
exhibition of extract of adrenal substance as well as 
after that of its active principle, adrenalin. 

Adrenalin glycosuria appears after comparatively 
small doses (.01-.1 mg.) and is readily provoked by 
a subcutaneous injection. The injection of one or two 
milligrams of adrenalin is followed in half an hour to 
two hours by a glycosuria lasting three hours. The 
glycosuria is always accompanied by a hyperglycemia. 

M Deutsch. Arch. f. klin. Med., 1901, LXXI, 146. 
61 Munch, med. Wchnschr., 1902, 478. 
B2 Amer. Jour. Physiol., 1906-07, XVII, 42. 



302 Manual of Vital Function Testing Methods 



5. Deviation of Complement in Functional Diagnosis of 
Suprarenal Disease 

Polito and Corelli 53 have attempted to apply the 
complement fixation test to the diagnosis of suprarenal 
gland disease (hyper function), using an alcoholic ex- 
tract of suprarenal gland as antigen. Their results 
were indeterminate. 



V. THE HYPOPHYSIS 

The pituitary gland or hypophysis, as is well known, 
is composed of two portions, a larger anterior epithelial, 
follicular, glandular portion and a posterior lobe con- 
sisting of connective and vascular structures. Between 
the two is a partly glandular, partly vascular por- 
tion, the pars intermedia. The whole organ is con- 
tained in a bony inclosure, the sella turcica, or pituitary 
fossa of the sphenoid bone. 

Since Marie first described the disease, acromegaly, 
and Rogowitch noted hypertrophy of the pituitary 
after thyroidectomy, both of which took place in 1886, 
a very large literature has sprung into existence con- 
cerning the physiology and pathology of the hypoph- 
ysis. 

The deep situation of this interesting organ at the 
base of the brain makes experimental investigation very 
difficult. The embryological and histological differ- 
ences between the anterior and posterior lobe of the 
hypophysis, made it extremely probable early in the 
history of these investigations that a different func- 
tional activity must be attributed to the two portions. 

M La Nouva Riv. Clin. Terap., 1911, XIV, 482. 



The Ductless Glands 303 

In this respect there is an analogy with some of the 
other ductless glands. 

The differentiation of the two systems in the hypoph- 
ysis, from the standpoint of pathology, is especially 
difficult because of the confined space in which the organ 
is lodged, making it almost inevitable that disease of 
one portion will affect the other. 

The name of Cushing in our country is intimately 
associated with our knowledge of the hypophysis on 
account of his extensive experimental and clinical in- 
vestigations. 54 

There is still much to be learned concerning the 
physiology and pathology of the hypophysis. Certain 
facts, are, however, pretty well agreed upon. The 
pituitary is probably essential to life, i. e., it is a vital 
organ. After its removal, animals soon die with severe 
cachexia. The secretion of the posterior lobe is sup- 
posed to gain access to the cerebrospinal fluid and the 
general circulation. It is concerned in regulating 
metabolism, particularly that of carbohydrates. It 
affects also the growth of fat. The internal secretion 
of the anterior lobe affects the processes of general 
metabolism and especially growth. 

Oliver and Shafer in 1895 55 discovered that ex- 
tracts of the pituitary produce when injected into blood 
vessels, a rise of blood pressure, like that of the ad- 
renals. Three years later Howell 56 discovered that 
only extracts of the posterior lobe have this effect. 

As with the thyroid and adrenals there is the same 
tendency among clinicians to regard the pathology 
of the hypophysis as being manifested by states of 
hyper- and hypo-function. Acromegaly or Marie's 

"The Pituitary Body and its Disorders, Phila., 1919. 
65 Jour, of Physiol., 1895, 18. 
86 Jour. Exper. Med., 1898, 3. 



304 Manual of Vital Function Testing Methods 

disease is regarded as a typical example of the former, 
while adiposo-genital dystrophy or Frohlich's disease 
is looked upon as an equally typical example of the 
latter. 

In our very brief account of the functional diag- 
nosis of the pituitaropathies, brief because so little of 
importance has been accumulated in medical literature, 
we shall consider the two states, opposite and distinct, 
producing diametrically opposite effects upon the or- 
ganism: hyperpituitarism and hypopituitarism. 

1. States of Hyperpituitarism 

The most typical example is acromegaly or Marie's 
disease, first described by him in 1886. 57 

Acromegaly is a chronic disorder characterized by 
an abnormal increase in the size of the nose, lips, tongue, 
lower jaw, hands and feet, by hyperplastic changes 
in the bones and soft parts, usually accompanied by 
considerable enlargement of the hypophysis and widen- 
ing of the sella turcica. Symptoms of increased intra- 
cranial pressure often occur. The vegetative nervous 
system is in a state of hyperirritability. The most 
common pathological finding is adenoma of the anterior 
part of the hypophysis. There is increase of function 
of the glandular hypophysis, a true hyperpituitarism. 

We shall not enter into the etiology and pathology 
or into the detailed account of the general symp- 
tomatology of acromegaly. As to the general diag- 
nosis of the disease it may be said to be quite easy in 
outspoken and typical cases. It is, however, difficult 
in the early stages, the so-called latent period of the 
disease. Acromegaly must be differentiated from cer- 
w Revue de Med., 1886, p. 298. 



The Ductless Glands 305 

tain diseases which may partially resemble it. Brain 
tumor, arthritis deformans, Graves' disease, diabetes, 
progressive muscular atrophy, have all been diagnosed 
as present when acromegaly really existed. 58 

Combinations of acromegaly with Basedowian or 
myxedematous symptoms sometimes occur in the earlier 
stages. X-ray examination of the sella turcica (Oppen- 
heim) is, as is now well known, of extreme diagnostic 
value. 

Two methods of functionally determining the exist- 
ence of hyperpituitarism have been suggested. They 
are: 

1. Demonstration of Disturbed Metabolism, as shown 
by increase of gas exchange. 

2. Demonstration of Alimentary or Spontaneous 
Glycosuria. 

1. Demonstration of Metabolic Disturbance as Shown 
by Increase of Gas Exchange as an Aid to the Func- 
tional Diagnosis of Hyperpituitarism. — Very little 
work has been done upon the study of the gas exchanges 
in acromegaly. That which has been done has been 
carried out with the Zuntz-Geppert apparatus. Cases 
have been examined by Magnus-Levy, Salomon, Bern- 
stein and Falta. 

In all, there are seven cases reported, in which de- 
tails are given as to the clinical facts and the amount 
of oxygen consumption and carbon dioxide production 
in ccm. per kilogram per minute. The figures vary for 
oxygen from 5.19 ccm. down to 3.55 and for C0 2 from 
4.33 down to 2.73. Falta states that the results of 
the cases so far investigated do not demonstrate an in- 

58 Modern Med., Osler-McCrae, 1915, IV, 813. (Dock.) 



306 Manual of Vital Function Testing Methods 

evitable increase in gas exchanges in acromegaly, as is 
the case in hyperthyroidism. 

It appears to be the opinion of Magnus-Levy and 
Salomon that if hyperpituitarism is uncomplicated by 
disorder of other glands of internal secretion (as thy- 
roid) there is no increase in the gas exchanges. In 
this opinion Falta 59 concurred. 

2. Demonstration of Spontaneous and Provocative 
Glycosuria as a Functional Test for Hyperpituitarism. 
— It has been known for some time that acromegaly is 
often accompanied by a temporary or permanent glyco- 
suria. Marie, who first described the disease, called at- 
tention to this fact. Borchard, from a study of 176 
cases, from the literature found spontaneous glycosuria 
reported in 63, and alimentary glycosuria in 8. In 8 
cases studied by Falta there was spontaneous or ali- 
mentary glycosuria in 5. Glycosuria appears only in 
the early stages of the disease, disappearing towards 
the end with the beginning of cachexia. 

The test for provocative alimentary glycosuria 
should be made in every case of suspected hyper- 
pituitarism. 

It will be unnecessary here to repeat the details of 
technique of the various tests for provocative gly- 
cosuria, since they have been fully dealt with under a 
previous chapter. The four tests there described are 
(1) the Cane Sugar Test, (2) the Glucose Test, (3) 
the Levulose Test, (4) the Galactose Test. 

The Glucose test has been more frequently used than 
the others in testing the carbohydrate powers in cases 
of suspected hyperpituitarism. 

58 Erkrankungen der Blutdrusen, Berl., 1913, p. 913. 



The Ductless Glands 307 

2. States of Hypopituitarism 

This state is typically represented in the so-called 
hypophyseal dystrophy of Frohlich, or dystrophia 
adiposo-genitalis. 

Frohlich, 60 in 1901, first emphasized the connection 
between destructive tumors of the hypophysis and 
the occurrence of the syndrome which bears his name 
and whose chief characteristics are a rapidly developing 
adiposity, infantilism of the genitalia and myxedem- 
atous degeneration of the subcutaneous tissues. Many 
authors have since reported cases. 

The opposite conditions with respect to gas ex- 
changes and glycosuria obtain in hypopituitarism as 
compared with hyperpituitarism. In hypopituitarism, 
therefore, the same functional tests are applied as were 
discussed above under acromegaly. The results, how- 
ever, will be the opposite. The gas exchanges will be 
diminished and glycosuria, both spontaneous and pro- 
vocative, will be negative. 

VI. THE VEGETATIVE NEEVOUS SYSTEM 

{Autonomic and Sympathetic) 

The very close relation which exists between the 
functional activity of the glands of internal secretion, 
and the vegetative nervous system, makes the vital in- 
tegrity of the one depend to a considerable extent upon 
the vital integrity of the other. For this reason it 
seems eminently proper to introduce into a work de- 
voted to the subject of vital function testing a de- 
scription of any methods which may have been devel- 
oped for testing the physiological status of the vege- 
tative nervous system. 

^Wien. klin. Rundschau, 1901, XLVII, 48. 



308 Manual of Vital Function Testing Methods 



1. Vagotonia and Sympathicotonia 

Much light has been recently thrown upon the re- 
lations which exist between disturbances of function of 
the autonomic and sympathetic portions of the vegeta- 
tive nervous system and certain fairly definite clinical 
syndromes. It has become a matter of common medi- 
cal parlance since the interesting researches of Ep- 
pinger and Hess * to speak of two opposite states of 
physiological activity of the vegetative nervous system, 
namely, vagotonia and sympathicotonia, both being 
supposed to be due to an increased tonus or physiologi- 
cal activity of the autonomic and sympathetic nervous 
system respectively. 

It has long been known that anatomically as well 
as physiologically and pharmacologically, two types of 
nervous function exist in the vegetative nervous system, 
namely, the sympathetic and autonomic ; fibres compos- 
ing the former springing from the dorsal and those of 
the latter from the cephalic and sacral extremities of 
the cerebrospinal axis. 

Various drugs, especially pilocarpine, muscarine, 
physostigmine, atropine, and adrenaline, have selec- 
tive actions upon the terminations of the sympathetic 
and autonomic nerves, and these actions, long known to 
the pharmacologist, have in a few instances been made 
the basis for tests to determine their physiological in- 
tegrity. 

Clinically, it has been found that many individuals, 
according to spontaneous or provoked reactions, may 
be classified as vagotonics or sympathicotonics accord- 
ing to the type and character of certain symptoms 
which they show or to their response to drugs or other 

*Die Vagotonie, 8°, Berlin, 1910; also Transl. by Kraus and 
Jelliffe, 8°, N. Y., 1915. 



The Vegetative Nervous System 309 

stimuli. Such symptoms may either be evident upon 
a superficial examination or will be discovered as a 
result of clinical investigation. 

Vagotonia. — Clinically, hypervagotonia is indicated 
by the presence of some of the following symptoms : 
paleness of the face, tendency to myopia, bradycardia, 
low blood pressure, moisture of the skin, asthma, mu- 
cous colitis, gastric hypersecretion, rapid gastric mo- 
tility, spasmodic constipation and pyloric spasm. Be- 
sides these manifestations in vagotonics there will be 
found a characteristic reaction to pilocarpine (see 
test below). The symptoms will be favorably influenced 
by atropine, many of them being diminished or removed 
entirely after the administration of this drug. 

Sympathicotonia. — Clinically, these cases present 
the opposite set of symptoms, especially tachycar- 
dia and hypertension. There will be found in sympa- 
thicotonics a hypersensitiveness to epinephrin, a rela- 
tive insusceptibility to pilocarpine and atropine and 
various symptoms of increased tone throughout the 
sympathetic system proper. 

The only tests which have been practically worked 
out for determining the functional integrity of the au- 
tonomic nervous system are two in number. (1) The 
oculocardiac reflex test of Ashner, (2) the pilocarpine 
test. Only one test has been suggested for directly 
determining the physiological status of the sympathetic 
portion and that is the so called adrenalin* test. 

#. The Oculocardiac Reflex Test of Ashner f 

Ashner in 1908 described this reflex which consists 
normally in a change of the heart's rate following pres- 
sure on one or both eyeballs. 
fWien. klin. Wchnschr, 1908, xxi, 1529. 



310 Manual of Vital Function Testing Methods 

The path of the reflex is centripetally through the 
fifth cranial nerve to the medulla and centrifugally 
through the vagus, or more rarely, the sympathetic 
nerves. 

Test: After having recorded a normal pulse rate 
for the individual to be examined, close the eyelids and 
exert gently increasing pressure by means of the ends 
of the fingers upon the bulbs of the eyes just under the 
supraorbital ridges (to avoid direct pressure upon the 
cornea) until the pressure becomes slightly uncomfort- 
able to the patient ; then maintain this pressure for one 
minute, taking the pulse rate at the same time with the 
aid of an assistant. In hypervagotonics this reflex 
which normally slows the pulse rate is exaggerated; 
that is to say, the pulse rate is slowed more than 10 
beats to the minute. During the test there may be some 
pain, flushing of face, movements of deglutition and 
apncea, but these symptoms readily subside upon re- 
moval of pressure. While in vagotonics the pulse rate 
is slowed more than ten beats to the minute below 
the normal rate, in sympathicotonics the reflex will be 
diminished or absent; in the first case the pulse rate 
will be increased and in the second it will be unaffected. 



3. Pilocarpine Test 

A hypodermic injection of .01 gm. of pilocarpine is 
administered. In the hypervagotonic or pilocarpine- 
sensitive patient there will be salivation, sweating, nau- 
sea, epiphora, flushing and a fall in blood pressure. 



The Vegetative Nervous System 311 



4. Adrenalin Test 

A hypodermic injection of .001 gm. of adrenalin is 
administered. In sympathicotonic or epinephrin-sen- 
sitive patients there will be a sensation of cold, with 
rigor, tremor, glycosuria and a rise in blood pressure. 



INDEX 



PAGE 

Abderhalden's test in hyperthyroidism. . . ., 287 

Abderhalden's method and liver function 58 

Aceto-nitril test of hyperthyroidism 279 

Adrenalinemia and hyperadrenalism .. .. 300 

Adrenalin glycosuria and hyperadrenalism 301 

Adrenalin-mydriasis test of hyperthyroidism 276 

Adrenalin test. ., 311 

Albarran's method of testing kidney function 84 

Ambard's coefficient and renal function 129 

Aminoaciduria, experimental provocative 38 

Aminoaciduria and liver function 38 

Ammonia nitrogen, estimation in urine (formalin 

method) 36 

Ammoniuria experimental provocative 37 

Antitoxic liver function 41 

Biliary liver function 58 

Bilirubinuria and liver function 63 

Blood coagulation and liver function ; . . . 52 

Blood studies and renal function 115 

Cammidge reaction 206 

Cane sugar test of liver function 17 

Cardiac efficiency factor of Tigerstedt 237 

Cardiac overload factor of Stone 241 

Cardiac reflex and heart function 231 

Cardiac strength, cardiac weakness ratio 238 

Cell nuclei test of pancreatic function 192 

Claude, Baudouin, Porak test of hyperthyroidism. . . 271 

Coagulation time and renal function 146 

313 



314 Index 

PAGE 

Coagulation time and liver function. . . ., 52 

Coagulation time, test for (Wright's method) 52 

Complement-fixation in adrenal disease . 302 

Complement-fixation test of hyperthyroidism 283 

Creatinin in the blood and renal function 137 

Cryoscopy of blood and renal function. . . . . 146 

Cryoscopy of urine and renal function Ill 

Diastase in feces and pancreatic function 202 

Diastase in urine and kidney function 110 

Diuretic drug tests of kidney function 86 

Ductless glands and vegetative nervous system 262 

t 

Ehrlich's urobilinogen test 63 

Electric conductivity of urine and kidney function. . 114 

Energometry 253 

Fat digestion and pancreatic function 194 

Ferment identification and pancreatic function 197 

Fibrinogen test of liver function. 54 

Fibrinolysis test of liver function 54 

Folin-Denis method of estimating incoagulable nitro- 
gen in blood. 124 

Galactose test of liver function 20 

Gas exchange and hyperpituitarism 305 

Ghedini's test of liver function 57 

Glucose test of liver function 18 

Glutoid capsule test of pancreatic function 192 

Glycosuria and hyperpituitarism 306 

Glycosuria and pancreatic function . 210 

Goodpasture's test of liver function 54 

Graupner's test of heart function 219 

Gymnastic test of heart function . 228 

Heart function tests 212 

Herz' test of heart function 227 

Hippuric acid test of renal function 149 



Index 315 

PAGE 

Hohlweg-Meyer method of estimating incoagulable 

nitrogen in blood 124 

Hunt's test of hyperthyroidism 279 

Hyperadrenalism 300 

Hyperpituitarism 304 

Hyperthyroidism, experimental 277 

Hyperthyroidism, tests for 266 

Hypoadrenalism 296 

Hypopituitarism 307 

Hypophysis cerebri . .. 302 

Hypophysis test of hyperthyroidism 271 

Hypothyroidism 290 

Incoagulable blood nitrogen and renal function 115 

Incoagulable nitrogen in blood, estimation of 124 

Index of urea excretion and renal function (McLean) 129 

Indicanuria and liver function 43 

Indigo carmine test of renal function 155 

Katzenstein's test of heart function 225 

Kidney function tests 75 

KjeldahTs nitrogen method S3 

v. Koranyi's test of renal function Ill 

Lactose test of renal function 149 

Levulose test of liver function 18 

Lipase estimation in blood 56 

Lipase in blood and liver function 56 

Lipase in feces. 204 

Liver function tests 15 

Loewi's test of hyperthyroidism 276 

Loewi's pupillary test 209 

Lowenhart's lipase estimation method 56 

Marshall's method of urea estimation in blood 119 

Marshall's method of urea estimation in urine 27 

Mendelsohn's test of heart function 223 

Metabolism test of hyperthyroidism 282 



316 Index 

PAGE 

Methylene blue test of liver function 42 

Methylene blue test of renal function 152 

Morris' method of estimating incoagulable nitrogen 

in blood 124 

Nitrogen coefficient and liver function 24 

Nitrogen estimation in urine (Kjeldahl's method) . . 33 

Nitrogen in urine and kidney function 91 

Oculocardiac test of Ashner. ...... . 309 

Pancreatic function tests 186 

Parathyroid glands 292 

Phenolsulphonephthalein test of renal function 157 

Phenoltetrachlorphthalein test of liver function .... 67 

Phloridzin test of renal function 149 

Pilocarpine test 310 

Polyuria, experimental, and kidney function 84 

Potassium iodide test of renal function 147 

Protein digestion tests of pancreatic function 190 

Residual nitrogen and liver function 40 

Rest nitrogen in blood and renal function 115 

Roche's test of liver function 42 

Rontgenoscopy and cardiac function 257 

Rowntree, Geraghty test of renal function. 157 

Rowntree, Horwitz, Bloomneld test of liver function 67 

Russian test of heart function 229 

Sahli's test of pancreatic function. . . 192 

Sanguinopoietic liver function 51 

Schmidt's test of pancreatic function 192 

Schott's test of heart function 229 

Selig's test of heart function 217 

Sodium chloride elimination and cardiac function. . . 232 

Sodium chloride elimination and renal function 87 

Sodium chloride estimation 90 

Sphygmobolography . ., 251 



Index 317 

PAGE 

Sphygmobolometry i 243 

Sphygmocardiography and cardiac function 258 

Sphygmomanometry and cardiac function 232 

Staircase test of heart function 217 

Starch digestion and pancreatic function 197 

Stone's cardiac overload factor 241 

Straus-Griinwald test of kidney function. .......... 86 

Sugar tests and adrenal function 298 

Sugar tests and liver function 16 

Sulpho-conjugation and liver function 46 

Suprarenal glands 295 

Sympathicotonia 308 

Test meal for nephritic function 95 

Thymus gland 293 

Thyroid gland 265 

Tigerstedt's cardiac efficiency factor 237 

Trypsin estimate in stomach contents 200 

Trypsin estimate in stools 198 

Urea in blood and renal function 115 

Urea elimination and kidney function 91 

Urea elimination and liver function 24 

Urea estimation in blood ( Marshall's method) 119 

Urea estimation in the blood (Van Slyke method) . . 32 

Urea estimation in urine (Marshall's method) 27 

Urea estimation in urine (Van Slyke's method) .... 30 

Urea provocative test of McCaskey 95 

Ureagenetic function tests of liver 22 

Uric acid in the blood and renal function 137 

Urinalysis as criterion of kidney function 81 

Urinary toxicity and renal function 115 

Urobilinogen test of liver function 63 

Urobilinuria and liver function 63 

Urobilinuria^ tests for 65 

Urochrome and kidney function 109 

Vagotonia . . . . , ,. . . . 308 



318 Index 

PAGE 

Venous pressure test of heart function 229 

Water tests of kidney function 85 

Whipple, Horwitz test of liver function. . . . 54* 

Whipple's lipase test of liver function 56 

Work-velocity ratio and cardiac function. 232 

Wright's coagulation-time method. .,. 53 



